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Boubaddi M, Eude A, Marichez A, Amintas S, Boissieras L, Celerier B, Rullier E, Fernandez B. Omentoplasty versus cecal mobilization after abdominoperineal resection: A propensity score matching analysis. Langenbecks Arch Surg 2024; 409:245. [PMID: 39120617 DOI: 10.1007/s00423-024-03439-0] [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: 11/28/2023] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Despite the minimally invasive approach and early rehabilitation, abdominal-perineal resection (APR) remains a procedure with high morbidity, notably due to postoperative trapped bowel ileus and perineal healing complications. Several surgical techniques have been described for filling the pelvic void to prevent abscess formation and ileus by trapped bowel loop. OBJECTIVE The aim of our study was to compare the post APR complications for cancer of two of these techniques, omentoplasty and cecal mobilization, in a single-center study from an expert colorectal surgery center. PATIENTS From 2012 to 2022, 84 patients were included, including 58 (69%) with omentoplasty and 26 (31%) with cecal mobilization. They all underwent APR at Bordeaux University Hospital Center. SETTINGS A propensity score was used to avoid confounding factors as far as possible. Patient and procedure characteristics were initially comparable. RESULTS The 30-day complication rate was significantly higher in the cecal mobilization group (53.8% vs. 5.2% p < 0.01), as was the rate of pelvic abscess (34.6% vs. 0% p < 0.001). CONCLUSION These findings suggest that, when feasible, omentoplasty should be considered the preferred method for pelvic reconstruction following APR.
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Affiliation(s)
- Mehdi Boubaddi
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France.
| | - Audrey Eude
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Arthur Marichez
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Samuel Amintas
- Tumor Biology and Tumor Bank Laboratory, CHU Bordeaux, 33600, Pessac, France
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, 33000, Bordeaux, France
| | - Lara Boissieras
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Bertrand Celerier
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Eric Rullier
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Benjamin Fernandez
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
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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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Lavie JL, Guidry RF, Palines PA, Dibbs RP, Melancon DM, Womac DJ, Stalder MW. The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction. Ann Plast Surg 2024; 93:239-245. [PMID: 39023410 DOI: 10.1097/sap.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. METHODS After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. RESULTS Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. CONCLUSIONS vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.
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Affiliation(s)
- Jennifer L Lavie
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Richard F Guidry
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Patrick A Palines
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Rami P Dibbs
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Daniel J Womac
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
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Colpaert J, Van De Winkel T. Fully robotic extralevator abdominoperineal excision with rectus abdominis flap harvest for perineal reconstruction: A video vignette. Colorectal Dis 2024. [PMID: 39044462 DOI: 10.1111/codi.17101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/06/2024] [Indexed: 07/25/2024]
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Kasai S, Kagawa H, Shiomi A, Hino H, Manabe S, Yamaoka Y, Maeda C, Tanaka Y, Kinugasa Y. Incidence and risk factors for perineal hernia after robotic abdominoperineal resection: a single-center, retrospective cohort study. Tech Coloproctol 2024; 28:79. [PMID: 38965146 DOI: 10.1007/s10151-024-02961-z] [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: 03/13/2024] [Accepted: 06/08/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Perineal hernia (PH) is a late complication of abdominoperineal resection (APR) that may compromise a patient's quality of life. The frequency and risk factors for PH after robotic APR adopting recent rectal cancer treatment strategies remain unclear. METHODS Patients who underwent robotic APR for rectal cancer between December 2011 and June 2022 were retrospectively examined. From July 2020, pelvic reinforcement procedures, such as robotic closure of the pelvic peritoneum and levator ani muscles, were performed as prophylactic procedures for PH whenever feasible. PH was diagnosed in patients with or without symptoms using computed tomography 1 year after surgery. We examined the frequency of PH, compared characteristics between patients with PH (PH+) and without PH (PH-), and identified risk factors for PH. RESULTS We evaluated 142 patients, including 53 PH+ (37.3%) and 89 PH- (62.6%). PH+ had a significantly higher rate of preoperative chemoradiotherapy (26.4% versus 10.1%, p = 0.017) and a significantly lower rate of undergoing pelvic reinforcement procedures (1.9% versus 14.0%, p = 0.017). PH+ had a lower rate of lateral lymph node dissection (47.2% versus 61.8%, p = 0.115) and a shorter operative time (340 min versus 394 min, p = 0.110). According to multivariate analysis, the independent risk factors for PH were preoperative chemoradiotherapy, not undergoing lateral lymph node dissection, and not undergoing a pelvic reinforcement procedure. CONCLUSIONS PH after robotic APR for rectal cancer is not a rare complication under the recent treatment strategies for rectal cancer, and performing prophylactic procedures for PH should be considered.
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Affiliation(s)
- S Kasai
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - H Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - A Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - H Hino
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - S Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Y Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - C Maeda
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Y Tanaka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Y Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Moiș E, Graur F, Horvath L, Furcea L, Zaharie F, Vălean D, Moldovan S, Al Hajjar N. Perineal Hernia Mesh Repair Using Only the Perineal Approach: How We Do It. J Pers Med 2023; 13:1456. [PMID: 37888067 PMCID: PMC10608043 DOI: 10.3390/jpm13101456] [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: 09/07/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Perineal hernia is a rare complication of rectal surgery. Different types of surgical approach have been described, but none of them have proven their superiority. Although there are many methods of closing the defect, we selected two cases to present from a series of five cases, in which the perineal hernia was successfully resolved surgically using only the perineal approach. The reconstruction of the perineal floor and closure of the defect were performed using a synthetic polypropylene mesh. The significance of this Technical Note article lies in the fact that we describe, step by step, a surgical technique for perineal hernia using just a perineal approach.
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Affiliation(s)
- Emil Moiș
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Florin Graur
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Levente Horvath
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Luminița Furcea
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Florin Zaharie
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Dan Vălean
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Septimiu Moldovan
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
| | - Nadim Al Hajjar
- 3rd Department of Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (E.M.); (L.H.); (L.F.); (F.Z.); (D.V.); (S.M.); (N.A.H.)
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania
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Loreti A, Arelli F, Spallone D, Bruno E, Abate O. The use of the internal pudendal artery perforator flap after abdominoperineal reconstruction: A single center study. J Plast Reconstr Aesthet Surg 2023; 84:87-92. [PMID: 37327737 DOI: 10.1016/j.bjps.2023.05.015] [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: 08/09/2022] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 06/18/2023]
Abstract
Abdominoperineal resection (APR) is still a valuable option in the presence of cancer recurrences or salvage surgery. Primary perineal closure after conventional APR curries a high rate of wound complications. A multidisciplinary approach with perineal soft tissue reconstruction surgical time improves the immediate and long-term prognosis of these patients. The aim of the study is to report our experience with the use of the internal pudendal artery perforator flap in perineal region reconstruction after APR. We performed 11 perineal region reconstructions after conventional APR between September 2016 and December 2020. In 8 cases the reconstruction was performed on previously irradiated tissues while in 2 cases the radiotherapy was carried out on the perineal tissues solely for adjuvant therapy. A rotation perforating flap was harvested in 8 cases, an advance island flap in 2 cases, and a propeller type in one case. All 11 flaps survived with no immediate postoperative major complications. Only one case showed dehiscence of the donor site wound healed with conservative treatment. Average hospitalization time was 11 days internal pudendal artery perforator flap represents a valid and reliable reconstructive solution after APR showing low complication rates and minimal donor site morbidity even in patients with previous radiotherapy.
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Affiliation(s)
- Andrea Loreti
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Floriana Arelli
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Diana Spallone
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Edoardo Bruno
- Department of Surgery ''P.Valdoni'', Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Via Giovanni Maria Lancisi, 2, 00161 Roma, Italy.
| | - Ornella Abate
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
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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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van Campenhout I, van Rees JM, Ceelen W, Tanis PJ, Rothbarth J, Verhoef C. Omentoplasty in Patients Undergoing Abdominoperineal Resection After Long-Course Chemoradiation for Locally Advanced and Locally Recurrent Rectal Cancer: A Comparative Single-Institution Cohort Study. Dis Colon Rectum 2023; 66:994-1002. [PMID: 36574322 DOI: 10.1097/dcr.0000000000002523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Omentoplasty is a commonly performed procedure after abdominoperineal resection for rectal cancer, but its effectiveness to reduce pelviperineal complications is not firmly established. OBJECTIVE This study aimed to assess the impact of omentoplasty on postoperative outcomes after long-course (chemo) radiotherapy and abdominoperineal resection in patients with locally advanced and locally recurrent rectal cancer. DESIGN Retrospective cohort study. SETTINGS Single center. PATIENTS All patients with locally advanced and locally recurrent rectal cancer undergoing abdominoperineal resection after neoadjuvant (chemo)radiation in a tertiary referral center between 2008 and 2020 were retrospectively reviewed. MAIN OUTCOME MEASURES Multivariable logistic and linear regression analyses were performed to analyze the association between omentoplasty and pelviperineal complications, duration of nasogastric tube drainage, and length of hospital stay. RESULTS A total of 305 patients were analyzed, of whom 245 underwent omentoplasty (80%). Pelviperineal complications occurred in 151 patients (50%) overall, in 125 patients (51%) with omentoplasty, and in 26 patients (43%) without omentoplasty. Independent predictors of pelviperineal complications in multivariable analyses were smoking (OR 2.68; 95% CI, 1.46-4.94) and high BMI (OR 1.68; 95% CI, 1.00-2.83), but not omentoplasty (OR 1.36; 95% CI, 0.77-2.40). The mean duration of nasogastric tube drainage was longer after omentoplasty (6 vs 4 d) with a significant association in multivariable analysis (β coefficient 1.97; 95% CI, 0.35-3.59). Patients undergoing omentoplasty had a significantly longer hospital stay (14 vs 10 d), and omentoplasty remained associated with a prolonged hospital stay after adjusting for confounding (β coefficient 3.05; 95% CI, 0.05-5.74). LIMITATIONS Retrospective design. CONCLUSION Omentoplasty was not associated with a reduced risk of the occurrence of short-term pelviperineal complications after abdominoperineal resection in patients undergoing long-course (chemo)radiotherapy. Furthermore, in patients undergoing omentoplasty, prolonged duration of nasogastric tube drainage and hospital stay was observed. See Video Abstract at http://links.lww.com/DCR/C124 . OMENTOPLASTIA EN PACIENTES SOMETIDOS A RESECCIN ABDOMINOPERINEAL DESPUS DE QUIMIORRADIOTERAPIA DE CURSO LARGO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO Y LOCALMENTE RECURRENTE ESTUDIO DE COHORTE COMPARATIVO DE UNA SOLA INSTITUCIN ANTECEDENTES:La omentoplastía es un procedimiento que se realiza comúnmente después de la resección abdominoperineal por cáncer de recto, pero su efectividad para reducir las complicaciones pelvicoperineales no está firmemente establecida.OBJETIVO:Evaluar el impacto de la omentoplastía en las complicaciones pelvicoperineales a corto plazo y los resultados postoperatorios después quimioradioterapia de curso largo y resección abdominoperineal en pacientes con cáncer de recto localmente avanzado y localmente recurrente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Centro único.PACIENTES:Se revisaron retrospectivamente todos los pacientes con cáncer de recto localmente avanzado y localmente recurrente sometidos a resección abdominoperineal después de quimioradiación neoadyuvante en un centro de referencia de tercer nivel entre 2008 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis de regresión lineal y logística multivariable para examinar la asociación entre la omentoplastía y las complicaciones pelvicoperineales (p. ej., problemas de heridas perineales y abscesos pélvicos), la duración del drenaje por sonda nasogástrica y la duración de la estancia hospitalaria.RESULTADOS:Se analizaron un total de 305 pacientes de los cuales 245 fueron sometidos a omentoplastía (80%). Las complicaciones pelvicoperineales ocurrieron en 151 pacientes (50%) en general, y en 125 (51%) y 26 (43%) de los pacientes con o sin omentoplastía, respectivamente. Los predictores independientes de complicaciones pelvicoperineales en análisis multivariable fueron el tabaquismo (OR 2.68, IC del 95% 1.46 a 4.94) y un IMC alto (OR 1.68, IC del 95% 1.00 a 2.83), pero no la omentoplastía (OR 1.36, IC del 95% 0.77 a 2.40) . La duración media del drenaje por sonda nasogástrica fue mayor después de la omentoplastía (6 frente a 4 días) con una asociación significativa en el análisis multivariable (coeficiente β 1.97, IC del 95%: 0.35-3.59). Los pacientes que se sometieron a una omentoplastía tuvieron una estancia hospitalaria significativamente más larga (14 frente a 10 días), y la omentoplastía permaneció asociada con una estancia hospitalaria prolongada después de ajustar por factores de confusión (coeficiente β 3.05, IC del 95%: 0.05-5.74).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:La omentoplastía no se asoció con un riesgo reducido de aparición de complicaciones pelvicoperineales a corto plazo después de la resección abdominoperineal en pacientes sometidos a quimioradioterapia de larga duración. Adicionalmente, en los pacientes sometidos a omentoplastía se observó una duración prolongada del drenaje por sonda nasogástrica y la estancia hospitalaria. Consulte Video Resumen en http://links.lww.com/DCR/C124 . (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Ilia van Campenhout
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of GI Surgery and Cancer Research Institute Ghent (CRIG), Ghent University Hospital, Ghent, Belgium
| | - Jan M van Rees
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wim Ceelen
- Department of GI Surgery and Cancer Research Institute Ghent (CRIG), Ghent University Hospital, Ghent, Belgium
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Joost Rothbarth
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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10
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Fan CW, Chen PH, Jhou HJ, Cheng YC. Negative pressure wound management in perineal wound status post abdominoperineal resection and extralevator abdominoperineal excision: a meta-analysis and trial sequential analysis. Int J Colorectal Dis 2023; 38:73. [PMID: 36933148 DOI: 10.1007/s00384-023-04353-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE Recent evidence-based publications disclosed that negative pressure wound therapy (NPWT) may reduce the incidence rate of surgical site infection (SSI) and length of stay (LOS) compared with conventional drainage in patient status post abdominoperineal resection (APR) and extralevator abdominoperineal excision (ELAPE). METHODS Data sources: Eligible randomized controlled trials and retrospective and prospective studies published before January 2023 were retrieved from databases (Cochrane Library, PubMed, and Embase). STUDY SELECTION (a) The study involved patients undergoing ELAPE or APR with postoperative NPWT; (b) the study compared NWPT with conventional drainage and reported at least one outcome of interest (i.e., SSI); and (c) the study provided adequate information to calculate the effect estimated for meta-analysis. INTERVENTIONS We calculated the odds ratio (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). MAIN OUTCOME MEASURES The measure outcomes included surgical site infection(SSI) and length of stay (LOS). RESULTS Eight articles, involving 547 patients, met the selection criteria. Compared to conventional drainage, NPWT was associated with a significantly lower SSI rate (fixed effect, OR 0.29; 95% CI 0.18-0.45; I2 = 0%) in eight studies and 547 patients. Besides, NPWT was associated with a shorter LOS (fixed effect, MD - 2.00; CI - 2.60 to - 1.39; I2 = 0%) than conventional drainage in three studies and 305 patients. In a trial sequential analysis, the cumulative number of patients in the analyses of both outcomes exceeded the required information size and surpassed the significance boundary in favor of NPWT, suggesting conclusive results. CONCLUSION NPWT is superior to conventional drainage in both SSI rate and LOS, and the statistical power of SSI and LOS are confirmed by trial sequential analysis.
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Affiliation(s)
- Cheng-Wei Fan
- Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yi-Chiao Cheng
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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11
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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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12
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Rather AA, Fisher AL, Chun D, Mannion JD, Alexander EL. Closed Incisional Negative Pressure Therapy Reduces Perineal Wound Complications After Abdominoperineal Resection. Dis Colon Rectum 2023; 66:314-321. [PMID: 35001048 PMCID: PMC9829036 DOI: 10.1097/dcr.0000000000002289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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 ).
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Affiliation(s)
- Assar A. Rather
- Graduate Medical Education Department, Bayhealth Medical Center, Dover, Delaware
- Department of Surgery, Bayhealth Medical Center, Dover, Delaware
| | | | - Dain Chun
- Graduate Medical Education Department, Bayhealth Medical Center, Dover, Delaware
| | - John D. Mannion
- Department of Surgery, Bayhealth Medical Center, Dover, Delaware
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Yamamoto T, Yoshitomi M, Oshimo Y, Nishikawa Y, Hisano K, Nakano K, Kawai T, Okuchi Y, Iguchi K, Tanaka E, Fukuda M, Taura K, Terajima H. Ability of minimally invasive surgery to decrease incisional surgical site infection occurrence in patients with colorectal cancer and other gastroenterological malignancies. Front Surg 2023; 10:1150460. [PMID: 37123540 PMCID: PMC10130529 DOI: 10.3389/fsurg.2023.1150460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/20/2023] [Indexed: 05/02/2023] Open
Abstract
Background Surgical site infection (SSI) is one of the most important complications of surgery for gastroenterological malignancies because it leads to a prolonged postoperative hospital stay and increased inpatient costs. Furthermore, SSI can delay the initiation of postoperative treatments, including adjuvant chemotherapy, negatively affecting patient prognosis. Identifying the risk factors for SSI is important to improving intra- and postoperative wound management for at-risk patients. Methods Patients with gastroenterological malignancies who underwent surgery at our institution were retrospectively reviewed and categorized according to the presence or absence of incisional SSI. Clinicopathological characteristics such as age, sex, body mass index, malignancy location, postoperative blood examination results, operation time, and blood loss volume were compared between groups. The same analysis was repeated of only patients with colorectal malignancies. Results A total of 528 patients (330 men, 198 women; mean age, 68 ± 11 years at surgery) were enrolled. The number of patients with diseases of the esophagus, stomach, small intestine, colon and rectum, liver, gallbladder, and pancreas were 25, 150, seven, 255, 51, five, and 35, respectively. Open surgery was performed in 303 patients vs. laparoscopic surgery in 225 patients. An incisional SSI occurred in 46 patients (8.7%). Multivariate logistic regression analysis showed that postoperative hyperglycemia (serum glucose level ≥140 mg/dl within 24 h after surgery), colorectal malignancy, and open surgery were independent risk factors for incisional SSI. In a subgroup analysis of patients with colorectal malignancy, incisional SSI occurred in 27 (11%) patients. Open surgery was significantly correlated with the occurrence of incisional SSI (P = 0.024). Conclusions Postoperative hyperglycemia and open surgery were significant risk factors for SSI in patients with gastroenterological malignancies. Minimally invasive surgery could reduce the occurrence of incisional SSI.
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Affiliation(s)
- Takehito Yamamoto
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
- Correspondence: Takehito Yamamoto
| | - Mami Yoshitomi
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yoshiki Oshimo
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Yuta Nishikawa
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Koji Hisano
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Kenzo Nakano
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Takayuki Kawai
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Yoshihisa Okuchi
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Kohta Iguchi
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Eiji Tanaka
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Meiki Fukuda
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Kojiro Taura
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Hiroaki Terajima
- Department of Gastroenterological Surgery and Oncology, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
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Pai AA, Young-Sing Q, Bera S, Maheshwari K, Misra A. Analysis of clinical and patient-reported outcomes in post-ELAPE perineal reconstruction with IGAP flap – A 5-year review. JPRAS Open 2022; 34:10-20. [PMID: 36061405 PMCID: PMC9429127 DOI: 10.1016/j.jpra.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/14/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Extralevator abdominoperineal excisions (ELAPE) are now the accepted treatment option for low rectal cancers, which result in large perineal defects necessitating reconstruction. The aim of our study was to assess the clinical outcomes as well as the quality-of-life parameters (QOLP) following these reconstructions. Methods: A series of 27 patients who underwent ELAPE and immediate reconstruction with inferior gluteal artery perforator flaps (IGAP) between December 2013 to December 2018 were retrospectively analysed on patient demographics, disease and treatment, complications, and QOLP. Results: With a mean age of 71.6 years, all patients had low rectal cancers and underwent ELAPE (24 open, 3 lap-assisted) and immediate IGAP flap reconstruction. The follow-up period was 1 year. The overall perineal early minor complication rate was 25.9% and the early major complication rate of 14.8%. QOLP, such as tolerance to sit, perineal pain, perineal aesthetics, showed high patient satisfaction of 77.7%, 40.74%, and 66.6%, respectively at 1 year. The perineal hernia rate was 14.8% with all patients being female (p 0.0407; significant). Conclusion: IGAP flaps are a reliable option for reconstructing post-ELAPE defects with good patient satisfaction and outcomes.
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Affiliation(s)
- Ashwin Alke Pai
- Chang Gung Memorial Hospital, Linkou, Taiwan & Wexham Park Hospital, UK
- Corresponding author: Ashwin Alke Pai; FRCS Plast, No 4A012, 11-5, Wenhua 2nd Road, Guishan District, Taoyuan, Taiwan 333.
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15
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A Comparison of Perineal Myocutaneous Flaps Following Abdominoperineal Excision of the Rectum for Anorectal Pathology. Dis Colon Rectum 2022; 65:1316-1324. [PMID: 35156364 DOI: 10.1097/dcr.0000000000002271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types. OBJECTIVE To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology. DESIGN This was a retrospective comparative study. SETTING This study was conducted at a large, tertiary referral institution. PATIENTS Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded. MAIN OUTCOME MEASURES The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques. RESULTS A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05). LIMITATIONS This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size. CONCLUSION Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal. ANTECEDENTES La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.
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16
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Meuli JN, Hubner M, Martineau J, Oranges CM, Guillier D, Raffoul W, di Summa PG. Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: A retrospective cohort study. J Surg Oncol 2022; 127:40-47. [PMID: 36112361 PMCID: PMC10087003 DOI: 10.1002/jso.27092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Large and deep perineal defects following abdominal perineal resection (APR) are a challenge for reconstructive surgeons. Even if generally performed for oncological reasons, APR can be indicated as well in extended infection-related debridement for Hidradenitis suppurativa, Fournier's gangrene, or Crohn's disease. We aimed to compare the outcomes of two groups of patients with different indications for APR (infectious vs. oncological) after pedicled anterolateral thigh (ALT) flap coverage RESULTS: Forty-four consecutive pedicled ALT flap used for coverage after APR in 40 patients were analyzed. 26 patients (65%) underwent APR for oncological reasons and 14 patients (35%) for infectious reasons. The overall postoperative complications rate was significantly higher for infectious cases (76.5% vs. 40.7%, p = 0.0304). Major complications occurred in 52.9% of infectious cases versus 11.1% of oncological cases (p = 0.0045). Obesity and infectious etiology were independent risk factors for overall and major complications, respectively. CONCLUSION Patients undergoing APR for acute or chronic infections had significantly more overall and major complications than patients having oncological APR. Modified care might be considered, especially in obese patients, in terms of surgical debridement, antibiotic treatment modalities, and postoperative management.
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Affiliation(s)
- Joachim N. Meuli
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Martin Hubner
- Department of Visceral Surgery Lausanne University Hospital Lausanne Switzerland
| | - Jérôme Martineau
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Carlo M. Oranges
- Department of Plastic, Reconstructive and Aesthetic Surgery Geneva University Hospitals Geneve Switzerland
| | - David Guillier
- Unit of Facial, Plastic, Reconstructive, Aesthetic and Hand Surgery CHU Dijon Dijon France
| | - Wassim Raffoul
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Pietro G. di Summa
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
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Pérez-García A, García-Granero Á, Thione A, Frasson M, Sánchez-García A, Salmerón-González E, Simón E, Domingo S, García-Granero E. Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection. J Surg Oncol 2022; 126:1383-1388. [PMID: 36003058 DOI: 10.1002/jso.27068] [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: 02/06/2022] [Revised: 07/14/2022] [Accepted: 08/07/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection. METHODS A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space. RESULTS Forty-four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence. CONCLUSIONS The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.
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Affiliation(s)
- Alberto Pérez-García
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | | | - Alessandro Thione
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | - Matteo Frasson
- Department of General Surgery, La Fe University Hospital, Valencia, Spain
| | | | | | - Eduardo Simón
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology, La Fe University Hospital, Valencia, Spain
| | - E García-Granero
- Department of General Surgery, La Fe University Hospital, Valencia, Spain
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Shah R, Kamble R, Herieka M, Dalal M. A National Survey on Perineal Reconstruction Following Standard and Extralevator Abdominoperineal Excision: Current Practices and Trends in the UK. Cureus 2022; 14:e28339. [PMID: 36034060 PMCID: PMC9400553 DOI: 10.7759/cureus.28339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/05/2022] Open
Abstract
Background Challenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have given rise to an emerging multidisciplinary approach between colorectal and plastic surgeons. At present, there is a relative paucity of evidence on best practice. This study sought to assess current national practice concerning perineal reconstruction following APE/ELAPE in the United Kingdom (UK) and to determine the factors involved in reconstruction choice. Methodology An anonymised survey was circulated to consultant plastic surgeons at all 48 UK centres performing perineal reconstruction following APE/ELAPE. Responses were collected between October 2021 and April 2022. Results Complete responses were received from 24 units nationally. All units had a dedicated APE/ELAPE service. Overall, 70% adopted a standardised reconstructive approach, the most common being the inferior gluteal artery perforator flap (n = 11). Significant variation was identified in the reconstructive technique. Similar differences were observed in the perceived importance of surgical factors guiding the reconstructive decision-making process, the top priorities being the size of the defect and previous radiotherapy. Conclusions The variability of responses suggests a lack of national consensus on optimal reconstruction following APE/ELAPE, despite the majority of centres employing a standardised approach to reconstruction. Our study highlights important surgical decision-making factors and provides valuable insight to aid in developing national collaborative evidence-based guidelines on best practice.
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Salmenkylä T, Kilpivaara K, Ohtonen P, Rautio T, Mäkäräinen E. Case control study investigating the clinical utility of NPWT in the perineal region following abdominoperineal resection for rectal adenocarcinoma: a single center study. BMC Surg 2022; 22:296. [PMID: 35907824 PMCID: PMC9338595 DOI: 10.1186/s12893-022-01746-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/22/2022] [Indexed: 11/15/2022] Open
Abstract
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)
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Affiliation(s)
- Tellu Salmenkylä
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland.
| | - Katariina Kilpivaara
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Research Service Unit, Oulu University Hospital, Oulu, Finland.,The Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Oulu, Finland
| | - Tero Rautio
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Elisa Mäkäräinen
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
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Jackisch J, Jackisch T, Roessler J, Sims A, Nitzsche H, Mann P, Mees ST, Stelzner S. Tailored concept for the plastic closure of pelvic defects resulting from extralevator abdominoperineal excision (ELAPE) or pelvic exenteration. Int J Colorectal Dis 2022; 37:1669-1679. [PMID: 35750763 DOI: 10.1007/s00384-022-04196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE No standard exists for reconstruction after extralevator abdominoperineal excision (ELAPE) and pelvic exenteration. We propose a tailored concept with the use of bilateral gluteal V-Y advancement flaps in non-extended ELAPE and with vertical myocutaneous rectus abdominis muscle (VRAM) flaps in extended procedures. This retrospective study analyzes the feasibility of this concept. PATIENTS AND METHODS We retrieved all consecutive patients after ELAPE or pelvic exenteration for rectal, anal, or vulva cancer with flap repair from a prospective database. Perineal wound complications were defined as the primary endpoint. Outcomes for the two different flap reconstructions were analyzed. RESULTS From 2005 to 2021, we identified 107 patients who met the study criteria. Four patients underwent exenteration with VRAM flap repair after previous V-Y flap fashioning. Therefore, we report on 75 V-Y and 36 VRAM flaps. The V-Y group contained more rectal carcinomas, and the VRAM group exhibited more patients with recurrent cancer, more multivisceral resections, and longer operation times. Perineal wound complications occurred in 21.3% in the V-Y group and in 36.1% in the VRAM group (p = 0.097). Adjusted odds ratio for perineal wound complication was not significantly different for the two flap types. CONCLUSION Concerning perineal wound complications, our concept yields favorable results for V-Y flap closure indicating that this less invasive approach is sufficient for non-extended ELAPE. Advantages are a shorter operation time, less donor site morbidity, and the option of a second repair. VRAM flaps were reserved for larger wounds after pelvic exenteration or vaginal repair.
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Affiliation(s)
- Julia Jackisch
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Thomas Jackisch
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Joerg Roessler
- Clinic for Plastic and Aesthetic Surgery, Oberer Kreuzweg 8, Dresden, D-01097, Germany
| | - Anja Sims
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Holger Nitzsche
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Pia Mann
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Sören Torge Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany. .,Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, Leipzig, D-04103, Germany.
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Oversized lotus petal flap for reconstruction of extensive perineal defects following abdomino perineal resection. ANN CHIR PLAST ESTH 2022; 67:224-231. [DOI: 10.1016/j.anplas.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022]
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22
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Mathew DAP, Wagh DMS. Abdominoperineal Excision in current era. Cancer Treat Res Commun 2022; 32:100580. [PMID: 35668011 DOI: 10.1016/j.ctarc.2022.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
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Zhang YZ, Zhu XG, Song MX, Yao KN, Li S, Geng JH, Wang HZ, Li YH, Cai Y, Wang WH. Improving the accuracy and consistency of clinical target volume delineation for rectal cancer by an education program. World J Gastrointest Oncol 2022; 14:1027-1036. [PMID: 35646284 PMCID: PMC9124985 DOI: 10.4251/wjgo.v14.i5.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/24/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Accurate target volume delineation is the premise for the implementation of precise radiotherapy. Inadequate target volume delineation may diminish tumor control or increase toxicity. Although several clinical target volume (CTV) delineation guidelines for rectal cancer have been published in recent years, significant interobserver variation (IOV) in CTV delineation still exists among radiation oncologists. However, proper education may serve as a bridge that connects complex guidelines with clinical practice.
AIM To examine whether an education program could improve the accuracy and consistency of preoperative radiotherapy CTV delineation for rectal cancer.
METHODS The study consisted of a baseline target volume delineation, a 150-min education intervention, and a follow-up evaluation. A 42-year-old man diagnosed with stage IIIC (T3N2bM0) rectal adenocarcinoma was selected for target volume delineation. CTVs obtained before and after the program were compared. Dice similarity coefficient (DSC), inclusiveness index (IncI), conformal index (CI), and relative volume difference [ΔV (%)] were analyzed to quantitatively evaluate the disparities between the participants’ delineation and the standard CTV. Maximum volume ratio (MVR) and coefficient of variation (CV) were calculated to assess the IOV. Qualitative analysis included four common controversies in CTV delineation concerning the upper boundary of the target volume, external iliac area, groin area, and ischiorectal fossa.
RESULTS Of the 18 radiation oncologists from 10 provinces in China, 13 completed two sets of CTVs. In quantitative analysis, the average CTV volume decreased from 809.82 cm3 to 705.21 cm3 (P = 0.001) after the education program. Regarding the indices for geometric comparison, the mean DSC, IncI, and CI increased significantly, while ΔV (%) decreased remarkably, indicating improved agreement between participants’ delineation and the standard CTV. Moreover, an 11.80% reduction in MVR and 18.19% reduction in CV were noted, demonstrating a smaller IOV in delineation after the education program. Regarding qualitative analysis, the greatest variations in baseline were observed at the external iliac area and ischiorectal fossa; 61.54% (8/13) and 53.85% (7/13) of the participants unnecessarily delineated the external iliac area and the ischiorectal fossa, respectively. However, the education program reduced these variations.
CONCLUSION Wide variations in CTV delineation for rectal cancer are present among radiation oncologists in mainland China. A well-structured education program could improve delineation accuracy and reduce IOVs.
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Affiliation(s)
- Yang-Zi Zhang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiang-Gao Zhu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ma-Xiaowei Song
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Kai-Ning Yao
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shuai Li
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jian-Hao Geng
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Hong-Zhi Wang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yong-Heng Li
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yong Cai
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Wei-Hu Wang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing 100142, China
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Mori GA, Tiernan JP. Management of Perineal Wounds Following Pelvic Surgery. Clin Colon Rectal Surg 2022; 35:212-220. [PMID: 35966381 PMCID: PMC9374536 DOI: 10.1055/s-0042-1742414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Despite advancements in understanding and technique, there remain significant challenges in the management of a complex perineal wound following pelvic surgery. Complications including wound sepsis, fistulation, persistent sinus, and herniation produce additional morbidity and health care costs. This article details the methods of optimizing patient and operative factors to mitigate this risk, alongside strategies to deal with sequelae of wound failure.
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Affiliation(s)
- George A Mori
- John Goligher Colorectal Unit, St James's University Hospital, Leeds, United Kingdom
| | - Jim P Tiernan
- John Goligher Colorectal Unit, St James's University Hospital, Leeds, United Kingdom
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Abstract
BACKGROUND Perineal hernia is a well-known, rare complication following abdominoperineal resection for rectal cancer. Due to its rarity, the literature on its surgical repair is comprised of case reports and small case series, and not one surgical approach has been established as superior. OBJECTIVE This study aimed to identify the repair methods used at our institution and their outcomes. We hypothesized that a perineal approach would have a similar recurrence rate to a transabdominal repair with shorter hospital length of stay. DESIGN This study was a retrospective case series. SETTINGS This study was conducted in a large, single institution setting. PATIENTS Patients who underwent surgical repair for perineal hernia from January 2009 to December 2019 were included. MAIN OUTCOME MEASURES The primary outcomes were perineal hernia recurrence, surgical approach to repair, and length of stay. RESULTS We identified 36 patients who underwent surgical repair of perineal hernia at our institution. Twenty patients received neoadjuvant chemoradiation therapy. Most patients (29) had previously undergone abdominoperineal resection; 5 were robotic, 15 were laparoscopic, 1 was robotic converted to open, and 8 were open. Patients were repaired through a perineal approach (22) or transabdominally (14). The median length of stay was 4 days (1-12) after a perineal approach and 8 days (3-18) after a transabdominal approach. At a median follow-up of 12.7 months (1-72), there were 4 recurrences after perineal repair and 3 recurrences after transabdominal repair. LIMITATIONS This study was limited by its small sample size (36), the retrospective and nonrandomized nature of the case series, and a lack of routine postoperative imaging. A median follow-up length of 12.7 months may not be adequate to detect all recurrences. CONCLUSIONS This case series supports the perineal approach for surgical repair; it should be the first approach considered, as it is less invasive and may be associated with shorter length of stay compared to an open transabdominal approach. Male gender and neoadjuvant chemotherapy may be possible risk factors for the development of perineal hernia after abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B856. REPARACIN QUIRRGICA DE HERNIA PERINEAL POSOPERATORIA UN CASO PARA EL ABORDAJE PERINEAL ANTECEDENTES:La hernia perineal es una complicación rara y bien conocida después de la resección abdominoperineal por cáncer de recto. Debido a su rareza, la literatura sobre su reparación quirúrgica se compone de informes de casos y pequeñas series de casos, y ningún abordaje quirúrgico se ha establecido como superior.OBJETIVO:El presente estudio tuvo como objetivo identificar los métodos de reparación utilizados en nuestra institución y sus resultados. Presumimos que un abordaje perineal tendría una tasa de recurrencia similar a una reparación transabdominal, con una estancia hospitalaria más corta.DISEÑO:Ésta es una serie de casos retrospectiva.AJUSTES:El escenario fue una gran institución única.PACIENTES:Los pacientes que se sometieron a reparación quirúrgica por hernia perineal desde enero del 2009 hasta diciembre del 2019 se incluyeron en la revisión.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la recurrencia de la hernia perineal, el abordaje quirúrgico para la reparación y la duración de la estadía.RESULTADOS:Identificamos 36 pacientes que fueron sometidos a reparación quirúrgica de hernia perineal en nuestra institución. La mayoría de los pacientes recibieron quimiorradioterapia neoadyuvante (n = 20). La mayoría de los pacientes (n = 29) se habrían sometido previamente a una resección abdominoperineal (n = 5 robótica, n = 15 laparoscópica, n = 1 robótica convertida a abierta, n = 8 abierta). Los pacientes fueron reparados mediante un abordaje perineal (n = 22) o transabdominal (n = 14). La mediana de la estancia hospitalaria fue de 4 días (rango, 1-12) después de un abordaje perineal y de 8 días (rango 3-18) después de un abordaje transabdominal. En una mediana de seguimiento de 12,7 meses (rango, 1-72) hubo 4 recurrencias después de la reparación perineal y 3 recurrencias después de la transabdominal.LIMITACIONES:El tamaño de la muestra pequeño (n = 36), la naturaleza retrospectiva y no aleatorizada de la serie de casos, la falta de imágenes posoperatorias de rutina, la mediana de seguimiento de 12,7 meses puede no ser adecuada para detectar todas las recurrencias.CONCLUSIONES:Esta serie de casos apoya el abordaje perineal para la reparación quirúrgica; debe ser el primer abordaje considerado, ya que es menos invasivo y puede estar asociado con una estadía más corta en comparación con el abordaje transabdominal abierto. El sexo masculino y la quimioterapia neoadyuvante podrían ser posibles factores de riesgo para el desarrollo de hernia perineal después de la resección abdominoperineal. Consulte Video Resumen en http://links.lww.com/DCR/B856. (Traducción- Dr. Francisco M. Abarca-Rendon).
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Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study. Int J Colorectal Dis 2022; 37:1029-1034. [PMID: 35396618 DOI: 10.1007/s00384-022-04141-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 02/04/2023]
Abstract
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.
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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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Rossi SA, Martineau JJC, Guillier D, Hübner M, Hahnloser D, Raffoul W, di Summa PG. Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection. Dis Colon Rectum 2022; 65:373-381. [PMID: 34784314 DOI: 10.1097/dcr.0000000000002132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The vertical rectus abdominis flap is considered the gold standard in perineal reconstruction after oncological abdominoperineal resection; however, it has a nonnegligible donor site morbidity. The anterolateral thigh flap offers reliable soft tissue coverage. OBJECTIVE The aim was to analyze long-term outcomes of composite anterolateral thigh-vastus lateralis flaps in oncological abdominoperineal resections. DESIGN We conducted a retrospective cohort analysis of a prospectively maintained database. SETTINGS This study was conducted in the Lausanne University Hospital. Annually, approximately 10 oncological abdomioperineal resections are performed. Literature reports 7% to 20% of patients undergoing abdominoperineal resection require flap reconstruction; in our institution, approximately 2 patients with large defects after abdominoperineal resections required reconstruction. PATIENTS Twenty-nine pedicled anterolateral thigh-vastus lateralis flaps in 27 consecutive patients (mean age 63 years +/-11.2, 23 with radiochemotherapy) after abdominoperineal resection to cover large defects (median 190 cm2, 48-600 cm2) were analyzed. INTERVENTION Pedicled composite anterolateral thigh-vastus lateralis flaps were performed after oncological abdominoperineal resection. MAIN OUTCOME MEASURES Descriptive statistical analysis was conducted. Short- and long-term outcomes were analyzed, univariate and multivariate analyses were performed. Median follow-up was 16 months (12-48 months). RESULTS Flap-related postoperative complications occurred in 16 flaps; flap-survival was 100%. Multivariate logistic analysis identified initial defect size as predictive for complications. Patients with larger defects (≥ 190 cm2) had higher complication rates (p = 0.006). Long-term analysis revealed 3 chronic fistulae, 2 tumor recurrences, 1 flap dysesthesia, and one perineal acne inversa. LIMITATIONS Limitations include retrospective analysis, selection bias, and lacking a control group. Sample size limits statistical power. CONCLUSIONS The pedicled anterolateral thigh-vastus lateralis flap offers reliable, stable tissue with low morbidity and good long-term outcomes. Complications compared favorably with current literature describing perineal reconstructions with rectus abdominis flaps. The composite anterolateral thigh flap is a valid alternative without the setback of abdominal donor site morbidity. See Video Abstract at http://links.lww.com/DCR/B757.RESULTADOS DEL COLGAJO COMPUESTO ANTEROLATERAL DE MUSLO PARA LA RECONSTRUCCIÓN PERINEAL DESPUÉS DE LA RESECCIÓN ABDOMINOPERINEAL POST ONCOLÓGICAANTECEDENTES:El colgajo vertical de recto abdominal se considera el estándar de oro en la reconstrucción perineal después de la resección abdominoperineal oncológica, sin embargo, tiene una morbilidad no despreciable en el sitio donante. El colgajo anterolateral del muslo ofrece una cobertura confiable de los tejidos blandos.OBJETIVO:El objetivo fue analizar los resultados a largo plazo de los colgajos compuestos anterolaterales del muslo - vasto lateral - en resecciones abdominoperineales oncológicas.DISEÑO:Realizamos un análisis, retrospectivo, de tipo cohorte, de una base de datos mantenida prospectivamente.AJUSTES:Este estudio fue realizado en el hospital universitario de Lausanne. Anualmente se realizan aproximadamente 10 resecciones abdominoperineales oncológicas. La literatura reporta que entre el 7 y el 20% de los pacientes que se someten a una resección abdominoperineal requieren de reconstrucción con colgajo; en nuestra institución, aproximadamente 2 pacientes con grandes defectos tras la resección abdominoperineal requirieron reconstrucción.PACIENTES:Fueron analizados veintinueve colgajos pediculados anterolaterales de muslo - vasto lateral - en 27 pacientes consecutivos (edad media 63 años +/- 11,2, 23 con radio quimioterapia) después de la resección abdominoperineal para cubrir defectos grandes (mediana 190 cm2, 48-600 cm2).INTERVENCIÓN:Tras la resección abdominoperineal oncológica se realizaron colgajos pediculados compuestos anterolaterales de muslo - vasto lateral.PRINCIPALES MEDIDAS DE RESULTADO:Fue realizado un análisis estadístico descriptivo. Fueron analizados los resultados a corto y largo plazo - fueron realizados así mismo análisis uni y multivariados. La mediana de seguimiento fue de 16 meses (12-48 meses).RESULTADOS:Complicaciones postoperatorias relacionadas con el colgajo ocurrieron en 16 colgajos, la supervivencia del colgajo fue del 100%. El análisis logístico multivariado identificó al tamaño del defecto inicial como predictor de complicaciones. Aquellos pacientes con defectos más grandes (≥190 cm2) tuvieron mayores tasas de complicaciones (p = 0,006). El análisis a largo plazo reveló tres fístulas crónicas, dos recidivas tumorales, una disestesia de colgajo y un acné perineal inverso.LIMITACIONES:Las limitaciones incluyen análisis retrospectivo, sesgo de selección y falta de grupo de control. El tamaño de la muestra limita el poder estadístico.CONCLUSIONES:El colgajo pediculado anterolateral de muslo - vasto lateral - ofrece tejido confiable y estable con baja morbilidad y buenos resultados a largo plazo. Los resultados de las complicaciones se mostraron favorables con respecto a la literatura actual que describe reconstrucciones perineales con colgajos de recto abdominal. El colgajo compuesto anterolateral de muslo es una alternativa válida sin el revés de la morbilidad del sitio donante abdominal. Consulte Video Resumen en http://links.lww.com/DCR/B757. (Traducción-Dr. Osvaldo Gauto).
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Affiliation(s)
- Severin A Rossi
- Unit of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Jérôme J C Martineau
- Unit of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - David Guillier
- Unit of Facial, Plastic Reconstructive and Esthetic Surgery, Hand Surgery, Centre Hospitalier Universitaire Dijon Bourgogne, Dijon, France
| | - Martin Hübner
- Unit of Visceral Surgery, CHUV, University of Lausanne, Lausanne, Switzerland
| | - Dieter Hahnloser
- Unit of Visceral Surgery, CHUV, University of Lausanne, Lausanne, Switzerland
| | - Wassim Raffoul
- Unit of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Pietro G di Summa
- Unit of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
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Segev L, Schtrechman G, Kalady MF, Liska D, Gorgun IE, Valente MA, Nissan A, Steele SR. Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience. Dis Colon Rectum 2022; 65:361-372. [PMID: 34784318 DOI: 10.1097/dcr.0000000000002067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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).
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Affiliation(s)
- Lior Segev
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gal Schtrechman
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - I Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Aviram Nissan
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Girsang BM, Elfira E. Utilization of “Perineal Wound Image Application” In Perineal Wound Digital Image Screening. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: A variety of serious conditions can affect the perineum, from infections that clear up on their own to conditions that are dangerous or add to the patient’s discomfort. Data at the level of each zone are an important factor for determining the area of wound healing. Injury investigations should include the identification of the injury, the calculation of the area of the injury which is generally important in determining treatment.
AIM: This study aims to present the findings of determining the characteristics of the perineal wound category and determining the area of the wound using MATLAB programming.
MATERIALS AND METHODS: The trial data in this study used 10 digital images with the development of 1000 trials and resulted in an accuracy rate of 86%. Digital image application is designed with 11 categories of perineal wounds that include assessment of wound color and characteristics.
RESULTS: The use of the application was carried out by 21 midwife health workers with the results of 81% of applications making it easier for officers to classify wounds, and 85.7% stated that the application could be a guide in making decisions about perineal wound care. Determination of wound categories and perineal wound area in this program proves the ease for health workers in planning appropriate care and treatment. This makes it very easy for users to do programming so that users are not too bothered by programming logic and focus more on the logic of solving problems on a hand.
CONCLUSION: The development of innovative perineal wound screening applications will provide convenience in practicality and efficiency of use in the future.
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Blok RD, Sharabiany S, Stoker J, Laan ETM, Bosker RJI, Burger JWA, Chaudhri S, van Duijvendijk P, van Etten B, van Geloven AAW, de Graaf EJR, Hoff C, Hompes R, Leijtens JWA, Rothbarth J, Rutten HJT, Singh B, Vuylsteke RJCLM, de Wilt JHW, Dijkgraaf MGW, Bemelman WA, Musters GD, Tanis PJ. Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study). Ann Surg 2022; 275:e37-e44. [PMID: 33534231 DOI: 10.1097/sla.0000000000004763] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia. SUMMARY BACKGROUND DATA BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing). METHODS This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic. RESULTS Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome. CONCLUSIONS Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.
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Affiliation(s)
- Robin D Blok
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- LEXOR, Center for Experimental and Molecular Medicine, Oncode Institute, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Ellen T M Laan
- Department of Sexology and Psychosomatic Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Sanjay Chaudhri
- Department of Surgery, University Hospitals Leicester, Leicester, United Kingdom
| | | | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de IJssel, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Roel Hompes
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Joost Rothbarth
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Baljit Singh
- Department of Surgery, University Hospitals Leicester, Leicester, United Kingdom
| | | | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Porwal A, Kundu GC, Bhagwat G, Butti R. Herbal medicine AnoSpray suppresses proinflammatory cytokines COX-2 and RANTES in the management of hemorrhoids, acute anal fissures and perineal wounds. Exp Ther Med 2021; 23:86. [PMID: 34938368 PMCID: PMC8688930 DOI: 10.3892/etm.2021.11009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/30/2021] [Indexed: 12/03/2022] Open
Abstract
Hemorrhoids, anal fistula and fissure are common anorectal complications. Anorectal diseases are associated with severe pain, inflammation, swelling, itching and bleeding. These diseases may be managed with different medical treatments or surgical procedures, depending on their severity. Surgical procedures, however, are highly invasive and are associated with higher costs and the possibility of recurrence. In addition, surgical removal of fistula-in-ano leads to the formation of perineal wounds. Therefore, developing therapeutic interventions that are effective in alleviating inflammation and pain are desirable for the effective management of anorectal diseases. Herbal compounds have previously been indicated to suppress inflammation and pain in different pathological conditions. The aim of the present study was to examine the effects elicited by a polyherbal formulation, AnoSpray®, on the migration of inflammatory cells and on the expression of inflammatory cytokines in anorectal diseases. The effect of AnoSpray on cell viability and migration was studied using MTT and wound-migration assays, respectively. Furthermore, the effects of AnoSpray on the expression of the inflammatory cytokines regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF, as well as on cyclooxygenase-2 (COX)-2, were investigated using western blot analysis. The expression of RANTES and COX-2 in human hemorrhoid specimens was also analyzed to corroborate the in vitro findings. The results obtained revealed that AnoSpray did not exhibit any cytotoxic effects; however, it did lead to a significant suppression in the migration of RAW 264.7 and BJ cells. Furthermore, the results suggested that AnoSpray suppressed the expression of the inflammatory cytokines RANTES and VEGF, and also the expression of COX-2. In addition, RANTES and COX-2 were significantly downregulated in the clinical specimens of AnoSpray-treated hemorrhoids compared with the controls. Taken together, the results of the present study suggested that AnoSpray may be a potential therapeutic agent in the treatment of bleeding hemorrhoids, anal fissures and perineal wounds.
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Affiliation(s)
- Ashwin Porwal
- Healing Hands Clinic, Pune, Maharashtra 411001, India
| | - Gopal C Kundu
- Laboratory of Tumor Biology, Angiogenesis and Nanomedicine Research, National Centre for Cell Science, Pune, Maharashtra 411007, India.,School of Biotechnology and Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Institute of Eminence, Bhubaneswar, Odisha 751024, India
| | - Gajanan Bhagwat
- R&D Center, Healing Hands & Herbs Pvt. Ltd., Pune, Maharashtra 411002, India
| | - Ramesh Butti
- Laboratory of Tumor Biology, Angiogenesis and Nanomedicine Research, National Centre for Cell Science, Pune, Maharashtra 411007, India.,R&D Center, Healing Hands & Herbs Pvt. Ltd., Pune, Maharashtra 411002, India
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A meta-analysis of low Hartmann's procedure versus abdominoperineal resection for non-restorative treatment of rectal cancer. Int J Colorectal Dis 2021; 36:2585-2598. [PMID: 34272997 DOI: 10.1007/s00384-021-03993-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
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.
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West JD, Kim ME, Lapalma DM, Vergara-Lluri M, Conti P, Chambers TN, Swanson MS. 18FDG-PET/CT Specificity for the Detection of Lymphoma Recurrence in the Tonsils. OTO Open 2021; 5:2473974X211059081. [PMID: 34805720 PMCID: PMC8600558 DOI: 10.1177/2473974x211059081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/15/2021] [Indexed: 11/18/2022] Open
Abstract
Objective In patients with a history of lymphoma who demonstrate palatine tonsil uptake
on posttreatment PET/CT (positron emission tomography/computed tomography),
tonsillectomy is often performed to evaluate for lymphoma recurrence.
However, predictive clinical and imaging factors for true tonsil recurrence
in this setting are not well established; this will be explored herein. Study Design Retrospective case series. Setting Patients treated at a tertiary medical center from January 2008 to May
2020. Methods Chart review was performed on all patients with a history of treated lymphoma
in clinical remission who presented for evaluation of abnormal PET/CT
imaging findings and subsequently underwent tonsillectomy. Results Among 15 patients who met inclusion criteria, 14 had benign findings on
surgical pathology, yielding a false-positive rate of 93%. The patient with
malignancy was identified on biopsy after inconclusive surgical pathology
and is the only documented case of recurrence in this specific patient
population throughout the literature. The patient presented with B symptoms,
irregularly shaped tonsils, increased lymph node activity on PET/CT, and
uptrending bilateral tonsil activity but with one of the lowest maximum
standardized uptake values of the cohort. The singular distinguishing
feature for the patient with recurrent disease was a prior tonsil biopsy
suspicious for recurrence, which prompted the otolaryngology referral. Conclusion PET/CT lacks specificity in identifying lymphoma recurrence in the
oropharynx. Clinical and radiographic features that were previously
considered concerning for recurrence are most likely not indicative of
malignancy in this patient population. Our findings call into question
whether tonsillectomy should be routinely performed in this patient
population.
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Affiliation(s)
- Jonathan D West
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mary E Kim
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dorian M Lapalma
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Maria Vergara-Lluri
- Hematopathology Section, Department of Pathology, University of Southern California, Los Angeles, California, USA
| | - Peter Conti
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tamara N Chambers
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mark S Swanson
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Rekonstruktion onkologischer Defekte der Perianalregion. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00575-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bernuth S, Jakubietz M, Isbert C, Reibetanz J, Meffert R, Jakubietz R, Schmidt K. Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer. Technol Health Care 2021; 30:815-825. [PMID: 34744033 DOI: 10.3233/thc-213021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. OBJECTIVE Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. METHODS 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. RESULTS Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. CONCLUSION The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.
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Affiliation(s)
- Silvia Bernuth
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Michael Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Christoph Isbert
- Department of General, Visceral and Coloproctological Surgery, Amalie Sieveking Hospital Hamburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Germany
| | - Rainer Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Rafael Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Karsten Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
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Reconstruction of Pelvic Exenteration Defect with Free Anterolateral Thigh Flap: A Case Report. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3774. [PMID: 34667704 PMCID: PMC8517310 DOI: 10.1097/gox.0000000000003774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
The pedicled anterolateral thigh flap, with or without the vastus lateralis muscle, has been described for pelvic exenteration defect reconstruction. However, its use as a free flap for this type of defect is not routinely followed. To reconstruct an extensive pelvic defect in the presence of two ostomies, we describe a free anterolateral thigh flap with deep inferior epigastric pedicles as recipient vessels.
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Johal KS, Mishra A, Alkizwini E, Whitehouse H, Batten G, Hachach-Haram N, Lancaster K, Constantinides J, Mohanna PN, Roblin P, Ross DA. Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP). J Plast Reconstr Aesthet Surg 2021; 75:137-144. [PMID: 34657821 DOI: 10.1016/j.bjps.2021.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/24/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Kavan S Johal
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom.
| | - Ankit Mishra
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | - Eman Alkizwini
- Department of Colorectal Surgery, St Mark's Hospital, Middlesex, United Kingdom
| | - Harry Whitehouse
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | - Gemma Batten
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | | | - Katie Lancaster
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | - Joannis Constantinides
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom; Department of Plastic Surgery, St Mark's Hospital, Middlesex, United Kingdom
| | - Pari-Naz Mohanna
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | - Paul Roblin
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | - David A Ross
- Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom; Department of Plastic Surgery, St Mark's Hospital, Middlesex, United Kingdom
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Maeda Y, Espin-Basany E, Gorissen K, Kim M, Lehur PA, Lundby L, Negoi I, Norcic G, O'Connell PR, Rautio T, van Geluwe B, van Ramshorst GH, Warwick A, Vaizey CJ. European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery. Colorectal Dis 2021; 23:2228-2285. [PMID: 34060715 DOI: 10.1111/codi.15718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/31/2022]
Abstract
This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.
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Affiliation(s)
- Yasuko Maeda
- Cumberland Infirmary and University of Edinburgh, Carlisle, UK
| | | | | | - Mia Kim
- Department of General, Gastrointestinal, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Lilli Lundby
- Department of Surgery Pelvic Floor Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ionut Negoi
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregor Norcic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - P Ronan O'Connell
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Tero Rautio
- Medical Research Center, University of Oulu, Oulu, Finland
| | | | | | - Andrea Warwick
- QEII Jubilee Hospital, Acacia Ridge, Queensland, Australia
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Lasso JM, Pinilla C, Vasquez W, Asencio JM. The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction. Ann Plast Surg 2021; 86:688-694. [PMID: 33346550 DOI: 10.1097/sap.0000000000002571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.
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Affiliation(s)
- Jose M Lasso
- From the Department of Plastic and Reconstructive Surgery
| | - Carmen Pinilla
- From the Department of Plastic and Reconstructive Surgery
| | - Wenceslao Vasquez
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - J M Asencio
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
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Khoury A, Bailey S, Mackey SP. Optimal postoperative management of perineal flaps in oncologic patients undergoing extralevator abdominoperineal excision: An introduction of a postoperative monitoring and flap management protocol. J Perioper Pract 2021; 32:10-14. [PMID: 33957819 DOI: 10.1177/1750458920959565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is extensive discussion regarding method of perineal defect closure extralevator abdominoperineal excision, but little consideration of optimal postoperative management of the flaps, or use of Enhanced Recovery After Surgery in flap reconstruction. Literature review revealed little discussion of optimum postoperative care of perineal flaps following extralevator abdominoperineal excision. We have developed a protocol for postoperative care of perineal flaps for use in conjunction with colorectal Enhanced Recovery After Surgery pathways, easily followed in units not specialising in plastic surgery. The protocol was developed using translatable evidence from guidelines for flap care from other subspecialties, as well as the experience of management of post-extralevator abdominoperineal excision perineal flaps in our trust, with the aim of enabling early detection of deterioration in this complex cohort, with a multidisciplinary enhanced recovery approach.
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Affiliation(s)
| | - Simon Bailey
- Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
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Horch RE, Ludolph I, Arkudas A. [Reconstruction of oncological defects of the perianal region]. Chirurg 2021; 92:1159-1170. [PMID: 33904942 DOI: 10.1007/s00104-021-01394-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 01/13/2023]
Abstract
In addition to the progressive development of surgical oncological techniques for malignant tumors of the rectum, anal canal and vulva, reconstructive procedures after oncological interventions in the perianal region represent a cornerstone in the postoperative quality of life of patients. Modern treatment modalities for rectal cancer with neoadjuvant chemoradiotherapy increase the survival rate and simultaneously reduce the risk of local recurrence to 5-10%, especially by cylindrical extralevatory extirpation of the rectum. The price for increased surgical radicality and improved oncological safety is the acceptance of larger tissue defects. Simple suture closure of perineal wounds often does not primarily heal, resulting in wound dehiscence, surgical site infections and formation of chronic fistulas and sinuses. The interdisciplinary one-stage or two-stage reconstruction of the perianal region with well-vascularized tissue has proven to be a reliable procedure to prevent or control such complications.
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Affiliation(s)
- Raymund E Horch
- Plastisch- und Handchirurgische Klinik und Labor für Tissue Engineering und Regenerative Medizin, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg FAU, Krankenhausstraße 12, 91054, Erlangen, Deutschland.
| | - Ingo Ludolph
- Plastisch- und Handchirurgische Klinik und Labor für Tissue Engineering und Regenerative Medizin, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg FAU, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Andreas Arkudas
- Plastisch- und Handchirurgische Klinik und Labor für Tissue Engineering und Regenerative Medizin, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg FAU, Krankenhausstraße 12, 91054, Erlangen, Deutschland
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Do the Severity of Peritonitis and Stoma Creation Influence the Occurrence of Incisional Surgical Site Infections in Patients With Colorectal Perforation? Int Surg 2021. [DOI: 10.9738/intsurg-d-17-00086.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
To identify the risk factors for incisional surgical site infection (SSI) in patients undergoing emergency surgery for colorectal perforation.
Summary of Background Data
Emergency surgery for colorectal perforation carries an especially high risk of incisional SSI. Although the risk factors of incisional SSI after colorectal surgery have been analyzed, no study has focused exclusively on patients with colorectal perforation.
Methods
Patients with colorectal perforation who underwent emergent surgery from 2010 to 2015 were enrolled. The factors associated with the occurrence of postoperative incisional SSI were evaluated.
Results
We enrolled 108 patients with colorectal perforation who underwent an emergency operation. Of these, 13 patients who died within 30 days after surgery were excluded. The mean age of the 95 study patients was 70 ± 13 years; 48 (51%) patients were male. The incisional SSI group comprised 26 patients (27%). Multivariate logistic regression analysis showed that stoma creation [odds ratio: 11.34; 95% confidence interval: 2.06–214.14] was an independent risk factor for incisional SSI. However, none of the clinical indicators of severe peritonitis and sepsis, including body temperature, systolic blood pressure, heart rate, preoperative white blood cell count, and C-reactive protein, were associated with the occurrence of incisional SSI.
Conclusions
Stoma creation was an independent risk factor for postoperative incisional SSI. Therefore, in this patient population, meticulous postoperative wound management is essential.
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Roos E, Douissard J, Abbassi Z, Buchs NC, Toso C, Ris F, Meyer J. Prophylactic negative-pressure wound therapy for prevention of surgical site infection in abdominal surgery: a nationwide cross-sectional survey. Updates Surg 2021; 73:1983-1988. [PMID: 33837948 PMCID: PMC8500901 DOI: 10.1007/s13304-021-01017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022]
Abstract
Our objective was to determine current practice in Switzerland regarding the use of pNPWT in abdominal surgery. An online survey was carried out to evaluate the use of pNPWT among abdominal surgeons in Switzerland. One hundred and ten participants replied to the survey from 16.12.2019 to 15.01.2020. Eleven were excluded, leaving 99 responders for analysis. Seventy participants (70.7%) were using pNPWT, 3 (3%) have stopped using it and 26 (26.3%) have never used it. pNPWT was used on midline laparotomy by 63 responders (90%), closed stoma wounds by 21 (30%), closed perineal wounds by 20 (28.6%), Pfannenstiel incisions by 18 (23.7%), groin incisions by 16 (22.9%), subcostal incisions by 13 (18.6%), Mc Burney incisions by 3 (4.3%) and other incisions by 18 (25.7%). Forty-eight participants (68.6%) used pNPWT on less than 10% of patients, 14 (20%) on 10–25% of patients, six (8.6%) on 25–50% of patients and two (2.9%) on 75–100% of patients. Suggestions for improvement to pNPWT were: better sealing, recyclable system, better adaptation to the perineum, smaller device, reduced cost and possibility to check the surgical wound through the dressing. In conclusion, pNPWT is widely used among Swiss surgeons, mostly on midline incisions. However, most of them apply pNPWT on a small proportion of patients only. Suggestions for improvement were a better sealing for complex wounds, reduced cost and possibility to check the wound during the therapy.
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Affiliation(s)
- Elin Roos
- Department of Global Public Health, Karolinska Institutet, 171 77, Stockholm, Sweden.,County Council of Östergötland, Linköping University, Linköping, Sweden
| | - Jonathan Douissard
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Medical School, University of Geneva, 1205, Genève, Switzerland
| | - Ziad Abbassi
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Medical School, University of Geneva, 1205, Genève, Switzerland
| | - Nicolas C Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Medical School, University of Geneva, 1205, Genève, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Medical School, University of Geneva, 1205, Genève, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Medical School, University of Geneva, 1205, Genève, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Medical School, University of Geneva, 1205, Genève, Switzerland.
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45
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Sharp O, Kapur S, Shaikh I, Rosich-Medina A, Haywood R. The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study. J Plast Reconstr Aesthet Surg 2021; 74:2654-2663. [PMID: 33952435 DOI: 10.1016/j.bjps.2021.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022]
Abstract
The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.
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Affiliation(s)
- Olivia Sharp
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Sandeep Kapur
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Irshad Shaikh
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Anais Rosich-Medina
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Richard Haywood
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK; Department of Anatomy, Norwich Medical School, University of East Anglia, Norwich, UK
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46
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Meyer J, Roos E, Abbassi Z, Toso C, Ris F, Buchs NC. The role of perineal application of prophylactic negative-pressure wound therapy for prevention of wound-related complications after abdomino-perineal resection: a systematic review. Int J Colorectal Dis 2021; 36:19-26. [PMID: 32886194 PMCID: PMC7782377 DOI: 10.1007/s00384-020-03732-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Closed perineal wounds often fail to heal by primary intention after abdomino-perineal resection (APR) and are often complicated by surgical site infection (SSI) and/or wound dehiscence. Recent evidence showed encouraging results of prophylactic negative-pressure wound therapy (pNPWT) for prevention of wound-related complications in surgery. Our objective was to gather and discuss the early existing literature regarding the use of pNPWT to prevent wound-related complications on perineal wounds after APR. METHODS Medline, Embase, and Web of Science were searched for original publications and congress abstracts reporting the use of pNPWT after APR on closed perineal wounds. RESULTS Seven publications were included for analysis. Two publications reported significantly lower incidence of SSI in pNPWT patients than in controls with a risk reduction of about 25-30%. Two other publications described similar incidences of SSI between the two groups of patients but described SSI in pNPWT patients to be less severe. One study reported significantly lower incidence of wound dehiscence in pNPWT patients than in controls. CONCLUSION The largest non-randomized studies investigating the effect of pNPWT on the prevention of wound-related complications after APR showed encouraging results in terms of reduction of SSI and wound dehiscence that deserve further investigation and confirmation.
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Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland.
| | - Elin Roos
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Ziad Abbassi
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Nicolas C Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
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47
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McDonald K, Borger P, Webman R, Kwon S. Combined perineal hernia repair and abdominal parastomal hernia with mesh for sequela of an abdominoperineal resection. INTERNATIONAL JOURNAL OF ABDOMINAL WALL AND HERNIA SURGERY 2021. [DOI: 10.4103/ijawhs.ijawhs_45_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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48
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Nassar MK, Jordan DJ, Quaba O. The internal pudendal artery turnover (IPAT) flap: A new, simple and reliable technique for perineal reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:2104-2109. [PMID: 33455871 DOI: 10.1016/j.bjps.2020.12.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/09/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
Perineal defects can be a reconstructive challenge following abdomino-perineal excision of the rectum, pelvic exenteration or the excision of severe pilonidal disease. These defects often involve large perineal cavities and pelvic dead space with often poorly mobile soft tissues due to neoadjuvant chemoradiation. Because of the inherent challenges of wound healing in the perineal region, well vascularised and robust reconstruction is mandated. In this paper, we describe a novel perforator-based turnover flap for perineal reconstruction - the internal pudendal artery turnover flap (IPAT flap). The flap requires no visualisation or dissection of perforating vessels, has a reliable vasculature, is quick and straightforward to perform and allows for the effective reconstruction of deep three-dimensional defects following perineal excisions. This is a retrospective study. A cohort of 38 consecutive patients who underwent various reconstructions with the IPAT flap under a single surgeon were included between 2012 and 2019. At three months, 37 flaps were fully healed. There were no flap failures or partial flap losses. Complications were seen in 10 of 38 patients with nine of these being minor and one that requires a return to the theatre for washout secondary to a urinary leak. The Internal Pudendal Artery Turn Over Flap allows us to reconstruct three-dimensional defects following perineal surgery, achieving more significant mobilisation of the flap to fill deep dead space without the added complexity and additional operative time associated with perforator dissection. The IPAT flap can be used in several common perineal reconstructive challenges expeditiously - often at the end of lengthy oncological resections - with minimal donor site morbidity, and in our experience, yields reliable outcomes.
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Affiliation(s)
- M K Nassar
- Department of Plastic, Reconstructive and Burns Surgery, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK.
| | - D J Jordan
- Department of Plastic, Reconstructive and Burns Surgery, St John's Hospital, Lothian, UK
| | - O Quaba
- Department of Plastic, Reconstructive and Burns Surgery, Ninewells Hospital, Dundee, UK
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49
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Galliamov EA, Agapov MA, Markaryan DR, Kakotkin VV, Kazachenko EA, Kubyshkin VA. RECURRENT PERINEAL HERNIA — LAPAROSCOPIC SURGICAL TREATMENT: CLINICAL CASE. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-3-59-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Recurrent postoperative perineal hernia is a rare complication of such operation as posterior pelvic evisceration. This condition can reduce the quality of life in the postoperative period and requires surgical restoration of the impaired pelvic anatomy.Clinical case: A 54-year old female patient applied to the MSU University clinic in July 2020 with the protrusion in the perineal area. She was diagnosed with recurrent perineal postoperative hernia. She was diagnosed with rectal cancer T4N1M0 and uterine dysplasia in 2017, 6 courses of neoadjuvant polychemoradiation therapy were performed; she underwent extralevator abdominal-perineal resection with uterine extirpation and the permanent colostomy formation in 2018. A perineal postoperative hernia was diagnosed in March 2020, perineal transabdominal plastic surgery was performed with a mesh implant. A recurrent perineal hernia was diagnosed in April 2020, the patient underwent laparoscopic alloplasty with a composite mesh implant. On the 9th postoperative day, she was discharged in a satisfactory condition without any complaints.Conclusion: Postoperative perineal hernia is a fairly rare complication in surgical practice. The recurrent rate is quite high. The insufficient number of patients, the short follow-up period and the wide range of surgical treatment methods do not allow evaluating the results adequately. It is necessary to conduct large randomized clinical trials to assess the efficacy of surgical interventions and to determine the indications for certain procedures.
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Affiliation(s)
- E. A. Galliamov
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU); Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - D. R. Markaryan
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - V. V. Kakotkin
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - E. A. Kazachenko
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - V. A. Kubyshkin
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
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Yang Y, Yu L, Wang M, Mu Y, Li J, Shang F, Wu X, Liu T, Shi J. A new surgical approach of direct perineal wound full-thick closure for perineal wound of abdominoperineal resection for rectal carcinoma: A prospective cohort trial. Int Wound J 2020; 17:1817-1828. [PMID: 32755065 PMCID: PMC7754419 DOI: 10.1111/iwj.13470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022] Open
Abstract
Perineal wound complications after APR have high morbidity in the colorectal surgical department. Although some approaches have been figured out to solve this clinical focus, the outcomes are still not satisfied. Herein, this prospective comparative clinical trial has been designed to evaluate a new surgical procedure of direct perineal wound full-thick closure (DPWC), compared with conventional perineal wound closure (CPWC), with hopes of making wound healing with less complications. In addition, an evaluation of an incision negative wound pressure therapy, as another focus in this field, was also analysed in the DPWC group. A total of 44 participants in our department were recruited from March 2018 to March 2020, divided into two groups randomly, CPWC group and DPWC group. The patients' characteristics, such as age, gender, BMI, smoking, alcohol consumption, comorbidities, CEA level, and high-risk of invasion, were recorded without statistical significance between the CPWC group and DPWC group. After the same standard abdominal phase, these two groups were performed in different perineal phases. And then, operative and postoperative outcomes were analysed with different statistical methods. Data on wound healing time and length of stay in the DPWC group were shorter than those in the CPWC group (P < .05). Furthermore, cases of wound infection within 30 days in the DPWC group were also less than that in the CPWC group (P < .05). However, no difference was found between the incisional negative pressure wound therapy assisted group (NPA group) and non- incisional negative pressure wound therapy assisted group (non-NPA group). During this study, hypoalbuminemia, as an independent high-risk factor, impacted perineal wound healing. (P = .0271) In conclusion, DPWC is a new surgical approach, which can lead to a better outcome than DPWC, and it can be another surgical procedure for clinicians. In addition, hypoalbuminemia should be interfered for avoiding perineal wound complications.
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Affiliation(s)
- Yong‐Ping Yang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Ling‐Yun Yu
- The Department of Ear Nose and Throat Surgerythe First Hospital of Jilin UniversityChangchunChina
| | - Min Wang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Yu Mu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Jian‐Nan Li
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Feng‐Jia Shang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Xian‐Feng Wu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Tong‐Jun Liu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Jian Shi
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
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