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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 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] [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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Moraru DC, Pertea M, Luca S, Bejan V, Panuta A, Tatar R, Enescu DM, Scripcariu DV, Scripcariu V. Personalized Decisional Algorithms for Soft Tissue Defect Reconstruction after Abdominoperineal Resection for Low-Lying Rectal Cancers. Curr Oncol 2024; 31:3253-3268. [PMID: 38920730 PMCID: PMC11202520 DOI: 10.3390/curroncol31060247] [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: 04/29/2024] [Revised: 05/25/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Abdominoperineal resection (APR)-the standard surgical procedure for low-lying rectal cancer (LRC)-leads to significant perineal defects, posing considerable reconstruction challenges that, in selected cases, necessitate the use of plastic surgery techniques (flaps). PURPOSE To develop valuable decision algorithms for choosing the appropriate surgical plan for the reconstruction of perineal defects. METHODS Our study included 245 LRC cases treated using APR. Guided by the few available publications in the field, we have designed several personalized decisional algorithms for managing perineal defects considering the following factors: preoperative radiotherapy, intraoperative position, surgical technique, perineal defect volume, and quality of tissues and perforators. The algorithms have been improved continuously during the entire period of our study based on the immediate and remote outcomes. RESULTS In 239 patients following APR, the direct closing procedure was performed versus 6 cases in which we used various types of flaps for perineal reconstruction. Perineal incisional hernia occurred in 12 patients (5.02%) with direct perineal wound closure versus in none of those reconstructed using flaps. CONCLUSION The reduced rate of postoperative complications suggests the efficiency of the proposed decisional algorithms; however, more extended studies are required to categorize them as evidence-based management guide tools.
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Affiliation(s)
- Dan Cristian Moraru
- Department of Plastic Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (D.C.M.); (S.L.)
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
| | - Mihaela Pertea
- Department of Plastic Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (D.C.M.); (S.L.)
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
| | - Stefana Luca
- Department of Plastic Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (D.C.M.); (S.L.)
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
| | - Valentin Bejan
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
- First Surgery Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania
| | - Andrian Panuta
- Plastic, Reconstructive Surgery and Burns Clinic, “Sf. Spiridon” Emergency County Hospital, 700111 Iași, Romania;
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
| | - Raluca Tatar
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (D.M.E.)
- Department of Plastic, Reconstructive Surgery and Burns, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Dan Mircea Enescu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (D.M.E.)
- Department of Plastic, Reconstructive Surgery and Burns, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Dragos Viorel Scripcariu
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
- First Oncological Surgery Clinic, Regional Institute of Oncology (IRO), 700483 Iași, Romania
| | - Viorel Scripcariu
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (V.B.); (V.S.)
- First Oncological Surgery Clinic, Regional Institute of Oncology (IRO), 700483 Iași, Romania
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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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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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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Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis. Cancers (Basel) 2022; 14:cancers14174300. [PMID: 36077834 PMCID: PMC9454697 DOI: 10.3390/cancers14174300] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The rate of perineal complications after abdominoperineal reconstruction for the treatment of cancers ranges from 25% to 60% in the literature. It is well-established in current literature that direct closure has a higher complication rate than closure with a flap. Several reconstructive options have been proposed to fill the dead space with well-vascularized tissue. Every surgeon would like to be comfortable in selecting which flap has superiority in terms of surgical outcome. In the absence of a meta-analysis on the subject due to the scarcity of RCT and comparative studies, we used a proportional meta-analysis to analyze the surgical outcomes after reconstruction with either VRAM flap or gracilis flap following oncologic resection of the vulvo-perineal region. Abstract Pelvic exenteration and abdominoperineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy with high morbidity due to large pelvic defects. Flaps can help provide healthy, well-vascularized, non-irradiated tissues to fill pelvic dead space. We conducted a proportional meta-analysis to compare surgical outcomes of vertical rectus abdominus myocutaneous flap (VRAM) vs. gracilis flap for vulvo-perineal reconstruction following oncologic resection. A comprehensive literature search was conducted in the MEDLINE, PubMed, Embase, Google Scholar, and Cochrane Library databases. Proportional meta-analysis was performed to compare the surgical outcomes of using VRAM or gracilis flaps. Our review yielded 16 eligible studies. The pooled resolution rate of overall donor site complications for VRAM flap (pooled proportion = 0.576 [95% CI 0.387, 0.754]) was significantly higher than the pooled rate of overall donor site complications of gracilis flap (pooled proportion = 0.160 [95% CI 0.058, 0.295]). Partial and total flap necrosis were similar in both groups. There was no statistically significant difference between minor and major complications for both flaps. Both flaps can be used safely for vulvo-perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.
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Zhang C, Yang X, Bi H. Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. BMC Surg 2022; 22:304. [PMID: 35933336 PMCID: PMC9357311 DOI: 10.1186/s12893-022-01755-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. Methods A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months. Results The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications. Conclusions A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
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Affiliation(s)
- Chen Zhang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xin Yang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Hongsen Bi
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
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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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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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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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12
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Dayani F, Sheckter CC, Rochlin DH, Nazerali RS. System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection. Plast Reconstr Surg 2022; 149:225-232. [PMID: 34813526 DOI: 10.1097/prs.0000000000008661] [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: 11/26/2022]
Abstract
BACKGROUND Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection. METHODS Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction. RESULTS The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05). CONCLUSIONS Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Fara Dayani
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
| | - Clifford C Sheckter
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
| | - Danielle H Rochlin
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
| | - Rahim S Nazerali
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
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Alemrajabi M, Khavanin Zadeh M, Hemmati N, Banivaheb B, Alemrajabi F, Jahanian S, Bahadoram M, Barahman M. Inferior Part of Rectus Abdominis Muscle Flap Outcomes after Abdominoperineal Resection: A Case Series Pilot Study. World J Plast Surg 2021; 10:104-110. [PMID: 34912674 PMCID: PMC8662682 DOI: 10.29252/wjps.10.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The standard surgical treatment for low rectal cancer is abdominoperineal resection (APR). Comparing to primary closure, immediate flap reconstruction has shown to have good outcomes. We aimed to assess the inferior rectus abdominis muscle flap complications after APR surgery, a new method of reconstruction. METHODS This study was conducted from 2014 to 2016 in a single center in Firoozgar Hospital, Tehran, Iran. Eighteen patients who underwent pelvic floor closure with inferior part of abdominis rectus musculofascial flap were included enrolled. The sampling method used in this study was census. All patients had distal rectoanal malignancies. A checklist including age, gender, tumor location, complications after surgery, tumor type, length of hospital stay, length of operation, neoadjuvant chemotherapy and neoadjuvant radiotherapy history was filled for all patients. RESULTS Among 18 participants, 27.8% were female. The mean age of participants was 58.28 ± 17.86 yr (minimum of 19 and the maximum of 89 yr). The pathology of the tumor in all but one of the cases was adenocarcinoma (94.4%). The overall complication rate after surgery was 27.8%. In total, 80% received neoadjuvant chemoradiotherapy. In 12 months follow-up 2 patients needed reoperation. CONCLUSION Inferior part of rectus abdominis muscle flap was a reliable and comparable means of reconstruction after APR surgery with low rate of complications and mortality.
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Affiliation(s)
- Mahdi Alemrajabi
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Morteza Khavanin Zadeh
- Hasheminejad Kidney Center (HKC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Nima Hemmati
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Behrouz Banivaheb
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Fatemeh Alemrajabi
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Sepideh Jahanian
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mohammad Bahadoram
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maedeh Barahman
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
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Inferior Part of Rectus Abdominis Muscle Flap Outcomes after Abdominoperineal Resection: A Case Series Pilot Study. World J Plast Surg 2021. [DOI: 10.52547/wjps.10.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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15
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Stein MJ, Karir A, Hanson MN, Cavale N, Almoudaris AM, Voineskos S. Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons. J Reconstr Microsurg 2021; 38:89-95. [PMID: 34187060 DOI: 10.1055/s-0041-1729750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs). METHODS Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management. RESULTS Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%). CONCLUSION A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.
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Affiliation(s)
- Michael J Stein
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Canada
| | - Aneesh Karir
- Division of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, Canada
| | - Melissa N Hanson
- Division of General Surgery, McGill University, Montreal, Canada
| | - Naveen Cavale
- Division of Plastic and Reconstructive Surgery, Kings College, London, United Kingdom
| | - Alex M Almoudaris
- Division of General Surgery, University College Hospital, London, United Kingdom
| | - Sophocles Voineskos
- Division of Plastic and Reconstructive Surgery, McMaster University, Hamilton, Ontario, Canada
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Moraru DC, Scripcariu DV, Ferariu D, Scripcariu V, Filip B. Perineal eventration after abdominoperineal resection for rectal cancer: anatomical, surgical and clinico-pathological landmarks. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY 2021; 61:1111-1119. [PMID: 34171060 PMCID: PMC8343492 DOI: 10.47162/rjme.61.4.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of evolution, out of 620 patients with rectal cancer treated by curative surgery, 176 patients with lower ampullary rectal cancer treated by abdominoperineal resection (APR) with the closure of the defect by direct suture of the perineal floor were selected. Ten (5.6%) of them were diagnosed with PE. This paper shows the results of a retrospective study, which compares the clinico-pathological and therapeutic aspects of a subgroup of 166 patients (subgroup I) with APR without PE and a subgroup of 10 patients (subgroup II) with PE. Starting from the question of whether aspects can influence the evolution of PE, we aimed to investigate the similarities and differences between these two groups, from the histological, clinical and therapeutic points of view. Regarding the tumor, node, metastasis (TNM) staging, we encountered the following aspects: for the subgroup II with PE, pT3 predominated, stages N0 and N1 were equal (50%) and the absence of metastases (M0) was found in all cases; in subgroup I, pT3 and N0 also predominated, followed by N1 and N2, and for stage M, M0 is predominant, followed by M1. For the clinical profile of the PE group, the symptoms were characteristic, with the presence of the usual triggering factors [hysterectomy, radiochemotherapy and wide resection surgery – extralevatorial APR]. The therapeutic approach revealed various aspects, including plastic surgery procedures (direct closure, meshes, flaps) used in pelvic reconstruction. The accurate surgical technique applied in order to achieve oncological safety allowed for a longer survival, which favored the appearance of PE in addition to the other favoring factors. Our results underlined the clinico-pathological profile of the two subgroups, without being able to establish a correlation with the appearance and evolution of PE. However, the clinico-pathological risk factors for this condition are not yet fully defined. Therefore, reports based on the experience in the diagnosis and treatment of PE should bring valuable data, aiming to create the knowledge framework for prevention.
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Affiliation(s)
- Dan Cristian Moraru
- Department of Surgery I, Grigore T. Popa University of Medicine and Pharmacy, 1st Surgical Oncology Unit, Regional Institute of Oncology, Iaşi, Romania;
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A Novel Technique for Reconstruction After Abdominoperineal Resection: V-Y Partially De-epithelized Turnover Flap with Its Own Inherent Mesh—A Three-Case Report. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02913-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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18
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Elia J, Do NTK, Chang TNJ, Lai CH, Chou HH, Chang FCS, Huang JJ. Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps. J Reconstr Microsurg 2021; 38:10-26. [PMID: 33853124 DOI: 10.1055/s-0041-1727199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. METHODS A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. RESULTS Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. CONCLUSION In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.
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Affiliation(s)
- Jhonatan Elia
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nicholas T K Do
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tommy N-J Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chyong-Huey Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Hung-Hsueh Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Frank C-S Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
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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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Hellinga J, Rots M, Werker PMN, Stenekes MW. Lotus petal flap and vertical rectus abdominis myocutaneous flap in vulvoperineal reconstruction: a systematic review of differences in complications. J Plast Surg Hand Surg 2020; 55:67-82. [PMID: 33054472 DOI: 10.1080/2000656x.2020.1828902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps. Methods: A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines. Results: A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%). Conclusions: Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates. Abbreviations: APE: abdominoperineal excision; ELAPE: extra levator abdominoperineal excision; LP flap: lotus petal flap; NIH: National Institute of Health; NR: not reported; RCT: randomized controlled trial; VRAM flap: vertical rectus abdominis myocutaneous flap.
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Affiliation(s)
- Joke Hellinga
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathijs Rots
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M N Werker
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin W Stenekes
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Options and outcomes of soft tissue reconstruction in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2733. [PMID: 32440406 PMCID: PMC7209827 DOI: 10.1097/gox.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
Background: Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration. Methods: Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate. Results: A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m2 (IQR: 24.2–26.7 kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient. Conclusions: The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.
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Alemrajabi M, Moradi S, Jahanian S, Banivaheb B, Hemmati N, Safari S. Inferior part of rectus abdominis muscle flap: A case report. Med J Islam Repub Iran 2020; 33:111. [PMID: 32002390 PMCID: PMC6983492 DOI: 10.34171/mjiri.33.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Indexed: 01/13/2023] Open
Abstract
Background: Abdominoperineal resection (APR) is the standard surgical treatment for low-lying anorectal malignancies. It seems that immediate flap reconstruction has fewer complications compared to primary closure. There are several options for local flap reconstruction of perineal wound closure, and each specific flap method has its own advantages and disadvantages.
Case presentation: In this case report, a new method of reconstruction is presented which contains only the inferior part of the rectus abdominis muscle in 2 patients, one with unilateral and the other with bilateral involvement and they both underwent APR. Both patients were referred to the colorectal surgery clinic for APR by an oncologist. Both patients had severe constipation and both reported pain on defecation and rectorrhagia. Patient 1 received a unilateral inferior part of rectus abdominis muscle flap and patient 2 received a bilateral flap.
Conclusion: Immediate flap reconstruction after APR has fewer complications than primary closure and the inferior part of rectus abdominis muscle flap seems to be a possible means of reconstruction after APR.
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Affiliation(s)
- Mahdi Alemrajabi
- Department of Surgery, Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Moradi
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Jahanian
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Behrouz Banivaheb
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Nima Hemmati
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Safari
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
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Immediate Reconstruction After Colorectal Cancer Resection: A Cohort Analysis Through the National Surgical Quality Improvement Program and Outcomes Review. Ann Plast Surg 2020; 84:196-200. [PMID: 31904642 DOI: 10.1097/sap.0000000000002103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Colorectal cancer is one of the most common and fatal malignancies in the United States. When localized to the distal gastrointestinal tract, surgical therapy includes abdominoperineal resection (APR) or pelvic exenteration (PEX). Subsequent ablative defects are considerable, impart concerning morbidity, and often necessitate autologous reconstruction. The aim of this study was to assess postoperative outcomes after reconstruction of APR and PEX defects. METHODS The American College of Surgeons National Surgical Quality Improvement Program (2005-2017) was queried for patients undergoing APR for lower gastrointestinal malignancies with concurrent autologous reconstructions. Cases of disseminated cancer were excluded. Postoperative adverse event profiles, including rates of wound and systemic complications, were evaluated. Multivariate regression analysis controlling for age, sex, body mass index, and operative time was performed to calculate adjusted odds ratios (ORs). RESULTS A total of 1309 patients were identified as undergoing APR/PEX with concomitant reconstruction. The majority (96.9%) of reconstructions consisted of muscle, myocutaneous, fasciocutaneous, or omental pedicled flaps. Of the cohort, 45.7% experienced at least 1 all-cause complication within 30-days of the procedure. Having a limited or moderate frailty (frailty index of "1" or "2") was identified as a predictor of all-cause complications [OR, 1.556; 95% confidence interval (CI), 1.187-2.040, P = 0.001; and OR, 1.741; 95% CI, 1.193-2.541, P = 0.004, respectively], whereas smoking was a predictor of wound complications (OR, 1.462; 95% CI, 1.070-1.996, P = 0.017) and steroid use was a predictor of mild systemic complications (OR, 2.006; 95% CI, 1.058-3.805, P = 0.033). CONCLUSION Anorectal cancer resection often necessitates reconstruction secondary to postexenteration perineal defects. The incidence of postoperative complications is relatively high, and several risk factors are identified to help refine patient optimization.
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Laporte GA, Zanini LAG, Zanvettor PH, Oliveira AF, Bernado E, Lissa F, Coelho MJP, Ribeiro R, Araujo RLC, Barrozo AJJ, da Costa AF, de Barros Júnior AP, Lopes A, Santos APM, Azevedo BRB, Sarmento BJQ, Marins CAM, Loureiro CMB, Galhardo CAV, Gatelli CN, Quadros CA, Pinto CV, Uchôa DNAO, Martins DRS, Doria-Filho E, Ribeiro EKMA, Pinto ERF, Dos Santos EAS, Gozi FAM, Nascimento FC, Fernandes FG, Gomes FKL, Nascimento GJS, Cucolicchio GO, Ritt GF, de Oliveira GG, Ayala GP, Guimarães GC, Ianaze GC, Gobetti GA, Medeiros GM, Güth GZ, Neto HFC, Figueiredo HF, Simões JC, Ferrari JC, Furtado JPR, Vieira LJ, Pereira LF, de Almeida LCF, Tayeh MRA, Figueiredo PHM, Pereira RSAV, Macedo RO, Sacramento RMM, Cardoso RM, Zanatto RM, Martinho RAM, Araújo RG, Pinheiro RN, Reis RJ, Goiânia SBS, Costa SRP, Foiato TF, Silva TC, Carneiro VCG, Oliveira VR, Casteleins WA. Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer. J Surg Oncol 2019; 121:718-729. [PMID: 31777095 DOI: 10.1002/jso.25759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.
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Affiliation(s)
| | | | | | | | - Enio Bernado
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - Fernando Lissa
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | - Reitan Ribeiro
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Andre Lopes
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | - Cláudio V Pinto
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Eric R F Pinto
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | | | - Gunther P Ayala
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Gustavo Z Güth
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | - João C Simões
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - José C Ferrari
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | - Lucas F Pereira
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Ramon O Macedo
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | - Rosilene J Reis
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | - Tyrone C Silva
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
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Blok RD, Hagemans JAW, Burger JWA, Rothbarth J, van der Bilt JDW, Lapid O, Hompes R, Tanis PJ. Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer. Tech Coloproctol 2019; 23:751-759. [PMID: 31432332 PMCID: PMC6736901 DOI: 10.1007/s10151-019-02055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 07/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR. METHODS Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures. RESULTS Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35-44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8-12 days). CONCLUSIONS The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.
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Affiliation(s)
- R D Blok
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Meibergdreef 9, Post Box 22660, 1100 DD, Amsterdam, The Netherlands
- LEXOR, Centre for Experimental and Molecular Medicine, Oncode Institute, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J A W Hagemans
- Department of Surgical Oncology, Erasmus Medical Centre, Cancer Institute, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - J W A Burger
- Department of Surgical Oncology, Erasmus Medical Centre, Cancer Institute, Doctor Molewaterplein 40, Rotterdam, The Netherlands
- Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, Eindhoven, The Netherlands
| | - J Rothbarth
- Department of Surgical Oncology, Erasmus Medical Centre, Cancer Institute, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - J D W van der Bilt
- Department of Surgery, Flevo Hospital, Hospitaalweg 1, Almere, The Netherlands
| | - O Lapid
- Department of Plastic and Reconstructive Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Meibergdreef 9, Post Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Meibergdreef 9, Post Box 22660, 1100 DD, Amsterdam, The Netherlands.
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Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2343. [PMID: 31942365 PMCID: PMC6952152 DOI: 10.1097/gox.0000000000002343] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/15/2019] [Indexed: 01/01/2023]
Abstract
Abdominoperineal resection (APR) carries a high risk of morbidity. Preoperative risk assessment can help with patient counseling, minimize adverse outcomes, and guide surgeons in their choice of reconstruction. This study examined the impact of sarcopenia (low lean muscle mass) on postoperative complications after APR.
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Jerez González JA, Quiñones Sánchez C, Márquez Rodríguez F. Catastrophic Abdominal Wall After Repair of Enterocutaneous Fistula: A Case Study. J Wound Ostomy Continence Nurs 2019; 46:337-342. [PMID: 31274868 DOI: 10.1097/won.0000000000000539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Repair of an enterocutaneous fistula (ECF) is challenging, particularly when complications occur. This case describes the use of negative pressure wound therapy (NPWT) and microadhesive dressings with polyabsorbent fibers and an acrylic core, with and without lipidocolloid and nano-oligosaccharide factors, in the management of a patient with a large abdominal wound and ECF. CASE An 84-year-old woman underwent abdominoperineal resection with colostomy, hysterectomy, and subsequent chemotherapy and radiotherapy for colorectal cancer. She experienced complications, ultimately resulting in ECF of the jejunum. Initial management with NPWT was used to promote abdominal wound healing, while protecting exposed bowel loops proved challenging because of leakage of stoma effluent that impeded the formation of granulation tissue. In order to promote wound healing and prevent infection, we applied a microadhesive dressing composed of polyabsorbent fibers with an acrylic core and lipidocolloid and nano-oligosaccharide factors that facilitated autolytic debridement and healing. CONCLUSIONS Use of NPWT with the microadhesive dressing proved successful in the management of this complex and challenging ECF.
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Affiliation(s)
- José Antonio Jerez González
- José Antonio Jerez González, MSC, APN, RN, Bellvitge University Hospital, Barcelona, Spain. Cristina Quiñones Sánchez, COCN, RN, Bellvitge University Hospital, Barcelona, Spain. Francisca Márquez Rodríguez, RN, Bellvitge University Hospital, Barcelona, Spain
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Abstract
PURPOSE Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair. METHODS A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes. RESULTS Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2-127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted. CONCLUSION Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.
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Yang XY, Wei MT, Yang XT, He YZ, Hao Y, Zhang XB, Deng XB, Wang ZQ, Zhou ZQ. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis 2019; 21:138-155. [PMID: 30428157 DOI: 10.1111/codi.14471] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
AIM Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease. METHODS We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure. RESULTS Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.
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Affiliation(s)
- X Y Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - M T Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X T Yang
- Wound Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Y Z He
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Y Hao
- West China School of Public Health, Sichuan University, Chengdu, China
| | - X B Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X B Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Modified V-Y Fasciocutaneous Flap Reconstruction After Abdominoperineal Resection in Irradiated Patients Prevents Wound Dehiscence and Associated Complications. Ann Plast Surg 2019; 82:218-223. [DOI: 10.1097/sap.0000000000001672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018). Dis Colon Rectum 2018; 61:755-774. [PMID: 29878949 DOI: 10.1097/dcr.0000000000001114] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Reconstruction of the composite defect after extended abdominoperineal resection (eAPR): a clinical experience from Italy. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018. [DOI: 10.1007/s00238-017-1325-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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