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Kappos EA, Wendelspiess SR, Stoffel J, Djedovic G, Rieger UM, Bannasch H, Fritsche E, Constantinescu M, Andric M, Croner RS, Schmidt VJ, Plock J, Schaefer DJ, Horch RE. [Reconstruction of Oncological Defects in the Pelvic-perineal Region: Report on the Consensus Workshop at the 44th Annual Meeting of the DAM 2023 in Bern, CH]. HANDCHIR MIKROCHIR P 2024; 56:269-278. [PMID: 39137788 DOI: 10.1055/a-2358-1479] [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: 08/15/2024] Open
Abstract
The surgical-oncological treatment of pelvic and perineal malignancies is associated with a high complication rate and morbidity for patients. Modern multimodal treatment modalities, such as neoadjuvant radio-chemotherapy for anal or rectal cancer, increase the long-term survival rate while reducing the risk of local recurrence. Simultaneously, the increasing surgical radicality and higher oncological safety with wide resection margins is inevitably associated with larger and, due to radiation, more complex tissue defects in the perineal and sacral parts of the pelvic floor. Therefore, the plastic-surgical reconstruction of complex pelvic-perineal defects following oncological resection remains challenging. The reconstructive armamentarium, and thus the treatment of such defects, is broad and ranges from local, regional and muscle-based flaps to microvascular and perforator-based procedures. While the use of flaps is associated with a significant, well-documented reduction in postoperative complications compared to primary closure, there is still a lack of reliable data directly comparing the postoperative results of different reconstructive approaches. Additionaly, the current data shows that the quality of life of these patients is rarely recorded in a standardised manner. In a consensus workshop at the 44th annual meeting of the German-speaking Association for Microsurgery on the topic of "Reconstruction of oncological defects in the pelvic-perineal area", the current literature was discussed and recommendations for the reconstruction of complex defects in this area were developed. The aim of this workshop was to identify knowledge gaps and establish an expert consensus to ensure and continuously improve the quality of reconstruction in this challenging area. In addition, the importance of the "patient-reported outcome measures" in pelvic reconstruction was highlighted, and the commitment to its widespread use in the era of value-based healthcare was affirmed.
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Affiliation(s)
- Elisabeth A Kappos
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Séverin R Wendelspiess
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Julia Stoffel
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Gabriel Djedovic
- Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Landeskrankenhaus Feldkirch, Feldkirch, Österreich
| | - Ulrich M Rieger
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | - Holger Bannasch
- Klinik für Plastische-, Hand- und Ästhetische Chirurgie, Schwarzwald-Baar Klinikum Donaueschingen, Donaueschingen, Deutschland
| | - Elmar Fritsche
- Abteilung für Hand- und Plastische Chirurgie, Luzerner Kantonsspital, Luzern, Schweiz
| | | | - Mihailo Andric
- Klinik für Allgemein-, Viszeral-, Gefäss- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Roland S Croner
- Klinik für Allgemein-, Viszeral-, Gefäss- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Volker J Schmidt
- Klinik für Plastische Chirurgie und Handchirurgie, Kantonsspital St. Gallen, Sankt Gallen, Schweiz
| | - JanA Plock
- Klinik für Plastische Chirurgie und Handchirurgie, Kantonsspital Aarau, Aarau, Schweiz
| | - Dirk J Schaefer
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Basel, Schweiz
- Medizinische Fakultät, Universität Basel, Basel, Schweiz
| | - Raymund E Horch
- Plastische und Handchirurgische Klinik, Universitätsklinikum Erlangen, Erlangen, Deutschland
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Temperley HC, Shokuhi P, O'Sullivan NJ, Mac Curtain B, Waters C, Murray A, Buckley CE, O'Neill M, Mehigan B, McCormick PH, Kelly ME, Larkin JO. Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis. Ir J Med Sci 2024; 193:1721-1728. [PMID: 38532236 PMCID: PMC11294374 DOI: 10.1007/s11845-024-03651-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/05/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE/AIM Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. METHODS PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality. RESULTS Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49; CONCLUSION We highlight the advantage of VRAM flap closure over primary closure for perineal wounds following APR. However, tailoring operative strategy based on patient and disease factors remains important in optimising outcomes.
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Affiliation(s)
- Hugo C Temperley
- Department of Surgery, St. James's Hospital, Dublin, Ireland.
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.
| | - Poorya Shokuhi
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | | | - Caitlin Waters
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Alannah Murray
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Maeve O'Neill
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Brian Mehigan
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Michael E Kelly
- Department of Surgery, St. James's Hospital, Dublin, Ireland
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland
| | - John O Larkin
- Department of Surgery, St. James's Hospital, Dublin, Ireland
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Lavie JL, Guidry RF, Palines PA, Dibbs RP, Melancon DM, Womac DJ, Stalder MW. The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction. Ann Plast Surg 2024; 93:239-245. [PMID: 39023410 DOI: 10.1097/sap.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. METHODS After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. RESULTS Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. CONCLUSIONS vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.
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Affiliation(s)
- Jennifer L Lavie
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Richard F Guidry
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Patrick A Palines
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Rami P Dibbs
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Daniel J Womac
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
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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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Rinkinen JR, Fruge S, Welten VM, Kinsley S, Bleday R, Irani J, Yoo J, Goldberg JE, Melnitchouk N, Talbot SG. Long-term outcomes analysis of flap-based perineal reconstruction. J Gastrointest Surg 2024; 28:57-63. [PMID: 38353075 DOI: 10.1016/j.gassur.2023.11.006] [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: 06/24/2023] [Revised: 10/17/2023] [Accepted: 11/03/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND High-risk patients undergoing abdominoperineal resection and pelvic exenteration may benefit from immediate flap reconstruction. However, there is currently no consensus on the ideal flap choice or patient for whom this is necessary. This study aimed to evaluate the long-term outcomes of using pedicled gracilis flaps for pelvic reconstruction and to analyze predictors of postoperative complications. METHODS This was a retrospective review of a single reconstructive surgeon's cases between January 2012 and June 2021 identifying patients who underwent perineal reconstruction secondary to oncologic resection. Preoperative and outcome variables were collected and analyzed to determine the risk of developing minor and major wound complications. RESULTS A total of 101 patients were included in the study with most patients (n = 88) undergoing unilateral gracilis flap reconstruction after oncologic resection. The mean follow-up period was 75 months. Of 101 patients, 8 (7.9%) developed early major complications, and an additional 13 (12.9%) developed late major complications. Minor complications developed in 33 patients (32.7%) with most cases being minor wound breakdown requiring local wound care. Most patients (n = 92, 91.1%) did not develop donor site complications. Anal cancer was significantly associated with early major complications, whereas younger age and elevated body mass index were significant predictors of developing minor wound complications. CONCLUSIONS This study builds on our previous work that demonstrated the long-term success rate of gracilis flap reconstruction after large pelvic oncologic resections. A few patients developed donor site complications, and perineal complications were usually easily managed with local wound care, thus making the gracilis flap an attractive alternative to abdominal-based flaps.
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Affiliation(s)
- Jacob R Rinkinen
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Seth Fruge
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Vanessa M Welten
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Sarah Kinsley
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Ronald Bleday
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Jennifer Irani
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - James Yoo
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Joel E Goldberg
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Nelya Melnitchouk
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Simon G Talbot
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States.
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Pérez-García A, García-Vilariño E, García-Granero Á, Alonso-Carpio M, Sánchez-García A, Valverde-Navarro A, García-Granero E. Comparison of vertical and extended vertical rectus abdominis myocutaneous flaps. An anatomical study. J Plast Surg Hand Surg 2023; 57:153-156. [PMID: 35034570 DOI: 10.1080/2000656x.2021.2024554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap could be insufficient. To compare the dimensions of VRAM and eVRAM flaps an anatomical study was performed. Ten VRAM and ten eVRAM flaps were dissected in ten fresh adult cadavers. Length, width and volume of all the flaps were measured. Length and volume were significantly larger in eVRAM flap compared to VRAM flap (36.55 cm vs. 30.15, p=.005; and 315.5 vs. 244 mL, p=.012, respectively). No differences were observed in flap width. The eVRAM flap could be a better option than traditional VRAM for reconstruction of big pelviperineal defects when bulkier tissue, larger skin paddle and/or longer arch of rotation are needed for reconstruction.
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Affiliation(s)
- Alberto Pérez-García
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | | | | | - Miriam Alonso-Carpio
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
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Cataneo JL, Mathis SA, Del Valle DD, Perez-Tamayo AM, Mellgren AF, Gantt G, Alkureishi LWT. Outcomes of perineal wound closure techniques after abdominoperineal resections in rectal cancer: an NSQIP propensity score matched study. J Plast Surg Hand Surg 2023; 57:399-407. [PMID: 36433927 DOI: 10.1080/2000656x.2022.2144333] [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] [Indexed: 11/27/2022]
Abstract
Perineal defects following abdominoperineal resections (APRs) for rectal cancer may require myocutaneous or omental flaps depending upon anatomic, clinical and oncologic variables. However, studies comparing their efficacy have shown contradictory results. We aim to compare postoperative complication rates of APR closure techniques in rectal cancer using propensity score-matching. The American College of Surgeons Proctectomy Targeted Data File was queried from 2016 to 2019. The study population was defined using CPT and ICD-10 codes for patients with rectal cancer undergoing APR, stratified by repair technique. Perioperative demographic and oncologic variables were controlled for by propensity-score matching. Multivariate logistic regression analysis was performed for wound and major complications (MCs). Of the 3291 patients included in the study, 85% underwent primary closure (PC), 8.3% rectus abdominis myocutaneous (RAM) flap, 4.9% pedicled omental flap with PC, and 1.9% lower extremity (LE) flap repair. Primary closure rates were significantly higher for patients with stage T1 and T2 tumors (p < 0.001). RAM and LE flaps were most used with multi-organ resections, 24% and 25%, respectively (p < 0.001). Similarly, cases with T4 tumors used these flaps more frequently, 30% and 40%, respectively (p < 0.001). After propensity score matching for comorbidities and oncologic variables, there was no significant difference in 30-day postoperative wound or MC rates between perineal closure techniques. The complication rates of the different closure techniques are comparable when tumor stage is considered. Therefore, tumor staging and concurrent procedures should guide clinical decision making regarding the appropriate use of each technique.
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Affiliation(s)
- Jose L Cataneo
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sydney A Mathis
- College of Medicine, University of Illinois at Chicago, Rockford, IL, USA
| | - Diana D Del Valle
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alejandra M Perez-Tamayo
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Anders F Mellgren
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Gerald Gantt
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Lee W T Alkureishi
- Department of Surgery, Division of Plastic Reconstructive and Cosmetic Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Rather AA, Fisher AL, Chun D, Mannion JD, Alexander EL. Closed Incisional Negative Pressure Therapy Reduces Perineal Wound Complications After Abdominoperineal Resection. Dis Colon Rectum 2023; 66:314-321. [PMID: 35001048 PMCID: PMC9829036 DOI: 10.1097/dcr.0000000000002289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Perineal wound complications after abdominoperineal resection continue to be a significant challenge. Complications, ranging from 14% up to 60%, prolong hospitalization, increase risk of readmission and reoperation, delay the start of adjuvant therapy, and place psychological stress on the patient and family. OBJECTIVE This study aimed to evaluate the impact of closed incision negative pressure therapy on perineal wound healing. DESIGN This was a retrospective study. SETTINGS The study was conducted in an academic community hospital. PATIENTS Patients who underwent abdominoperineal resection from 2012 to 2020 were included. MAIN OUTCOME MEASURES Perineal wound complications within 30 and 180 days were the primary outcome measures. RESULTS A total of 45 patients were included in the study. Of these, 31 patients were managed with closed incision negative pressure therapy. The overall perineal wound complications were less frequent in the closed incision negative pressure therapy group (10/31; 32.2%) compared to the control group (10/14; 71.4%; = 5.99 [ p = 0.01]). In the closed incision negative pressure therapy group, 2 patients (20%) did not heal within 180 days and no patient required reoperation or readmission. In the control group, 4 patients (44%) had not healed at 180 days and 1 patient required flap reconstruction. When the effect of other variables was controlled, closed incision negative pressure therapy resulted in an 85% decrease in the odds of wound complications (adjusted OR 0.15 [95% CI, 0.03-0.60]; p = 0.01). LIMITATIONS The nonrandomized nature and use of historical controls in this study are its limitations. CONCLUSIONS The ease of application and the overall reduction in the incidence and severity of complications may offer an option for perineal wound management and possibly obviate the need for more expensive therapies. Further prospective controlled trials are required to effectively study its efficacy. See Video Abstract at http://links.lww.com/DCR/B895 . LA TERAPIA POR PRESIN NEGATIVA INCISIONAL CERRADA, REDUCE LAS COMPLICACIONES DE LA HERIDA PERINEAL DESPUS DE LA RESECCIN ABDOMINOPERINEAL ANTECEDENTES:Las complicaciones de la herida perineal, después de la resección abdominoperineal, continúan siendo un desafío importante. Las complicaciones, que van desde el 14% hasta el 60%, prolongan la hospitalización, aumentan el riesgo de reingreso y reintervención, retrasan el inicio de la terapia adyuvante y generan estrés psicológico en el paciente y su familia.OBJETIVO:Evaluar el impacto de la terapia de presión negativa con incisión cerrada en la cicatrización de heridas perineales.DISEÑO:Estudio retrospectivo.ENTORNO CLINICO:Hospital comunitario académico.PACIENTES:Se incluyeron pacientes sometidos a resección abdominoperineal entre 2012 y 2020.PRINCIPALES MEDIDAS DE VALORACION:Las complicaciones de la herida perineal dentro de los 30 y 180 días fueron las principales medidas de valoración.RESULTADOS:Se incluyeron en el estudio a un total de 45 pacientes. De estos, 31 pacientes fueron tratados con terapia de presión negativa con incisión cerrada. Las complicaciones generales de la herida perineal fueron menos frecuentes en el grupo de terapia de presión negativa con incisión cerrada (10/31, 32,2%) en comparación con el grupo de control (10/14, 71,4%) (X_1 ^ 2 = 5,99 [ p = 0,01]). En el grupo de terapia de presión negativa con incisión cerrada, dos pacientes (20%) no cicatrizaron en 180 días y ningún paciente requirió reintervención o readmisión. En el grupo de control, cuatro pacientes (44%) no habían cicatrizado a los 180 días y un paciente requirió reconstrucción con colgajo. Cuando se controló el efecto de otras variables, la terapia de presión negativa con incisión cerrada resultó con una disminución del 85% en las probabilidades de complicaciones de la herida (OR ajustado, 0.15 [IC 95%, 0,03-0,60]; p = 0,01).LIMITACIONES:La naturaleza no aleatoria y el uso de controles históricos en este estudio, son limitaciones.CONCLUSIÓNES:La facilidad de aplicación, reducción general de la incidencia y gravedad de las complicaciones, pueden ofrecer una opción para el manejo de las heridas perineales y posiblemente obviar la necesidad de tratamientos más costosos. Se necesitan más ensayos controlados prospectivos para efectivamente estudiar la eficacia. Consulte Video Resumen en http://links.lww.com/DCR/B895 . (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Assar A. Rather
- Graduate Medical Education Department, Bayhealth Medical Center, Dover, Delaware
- Department of Surgery, Bayhealth Medical Center, Dover, Delaware
| | | | - Dain Chun
- Graduate Medical Education Department, Bayhealth Medical Center, Dover, Delaware
| | - John D. Mannion
- Department of Surgery, Bayhealth Medical Center, Dover, Delaware
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Pai AA, Young-Sing Q, Bera S, Maheshwari K, Misra A. Analysis of clinical and patient-reported outcomes in post-ELAPE perineal reconstruction with IGAP flap – A 5-year review. JPRAS Open 2022; 34:10-20. [PMID: 36061405 PMCID: PMC9429127 DOI: 10.1016/j.jpra.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/14/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Extralevator abdominoperineal excisions (ELAPE) are now the accepted treatment option for low rectal cancers, which result in large perineal defects necessitating reconstruction. The aim of our study was to assess the clinical outcomes as well as the quality-of-life parameters (QOLP) following these reconstructions. Methods: A series of 27 patients who underwent ELAPE and immediate reconstruction with inferior gluteal artery perforator flaps (IGAP) between December 2013 to December 2018 were retrospectively analysed on patient demographics, disease and treatment, complications, and QOLP. Results: With a mean age of 71.6 years, all patients had low rectal cancers and underwent ELAPE (24 open, 3 lap-assisted) and immediate IGAP flap reconstruction. The follow-up period was 1 year. The overall perineal early minor complication rate was 25.9% and the early major complication rate of 14.8%. QOLP, such as tolerance to sit, perineal pain, perineal aesthetics, showed high patient satisfaction of 77.7%, 40.74%, and 66.6%, respectively at 1 year. The perineal hernia rate was 14.8% with all patients being female (p 0.0407; significant). Conclusion: IGAP flaps are a reliable option for reconstructing post-ELAPE defects with good patient satisfaction and outcomes.
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Affiliation(s)
- Ashwin Alke Pai
- Chang Gung Memorial Hospital, Linkou, Taiwan & Wexham Park Hospital, UK
- Corresponding author: Ashwin Alke Pai; FRCS Plast, No 4A012, 11-5, Wenhua 2nd Road, Guishan District, Taoyuan, Taiwan 333.
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A Comparison of Perineal Myocutaneous Flaps Following Abdominoperineal Excision of the Rectum for Anorectal Pathology. Dis Colon Rectum 2022; 65:1316-1324. [PMID: 35156364 DOI: 10.1097/dcr.0000000000002271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types. OBJECTIVE To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology. DESIGN This was a retrospective comparative study. SETTING This study was conducted at a large, tertiary referral institution. PATIENTS Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded. MAIN OUTCOME MEASURES The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques. RESULTS A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05). LIMITATIONS This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size. CONCLUSION Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal. ANTECEDENTES La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.
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11
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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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12
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Oversized lotus petal flap for reconstruction of extensive perineal defects following abdomino perineal resection. ANN CHIR PLAST ESTH 2022; 67:224-231. [DOI: 10.1016/j.anplas.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022]
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13
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Vertical Rectus Abdominis Myocutaneous Flap to Reconstruct Thigh and Groin Defects: A Retrospective Cohort and Systematic Review. J Plast Reconstr Aesthet Surg 2022; 75:1893-1901. [DOI: 10.1016/j.bjps.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/07/2021] [Accepted: 01/08/2022] [Indexed: 11/20/2022]
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Kim E, Fernando C, McCombie A, Bailey W, Frizelle F, Glyn T, Porter C, Wakeman C, Creagh T. Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction - a supraregional experience. J Plast Reconstr Aesthet Surg 2021; 75:1158-1163. [PMID: 34895852 DOI: 10.1016/j.bjps.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/01/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vertical rectus abdominis myocutaneous (VRAM) flap has proven to be a robust reconstruction method following radical pelvic surgery. Radical pelvic surgery is associated with high morbidity due to pelvic complications and non-healing perineal wounds, as a result of non-collapsible pelvic dead space and pre-operative adjuvant radiotherapy insult. VRAM flap reconstruction addresses both issues by obliterating the dead space and introducing healthy non-radiated tissue. However, flap reconstruction complications can include donor site hernias (abdominal wall), perineal hernias, and flap-specific complications. This study aimed to evaluate the abdominal and perineal hernia rates as well as radiological evidence of flap vascularity post-operatively. METHODS We conducted a retrospective analysis of patients who underwent a VRAM flap reconstruction following radical pelvic surgery at Christchurch hospital over a 10-year period. We identified the presence of donor site hernias (abdominal wall hernias), perineal hernias, and flap vascularity on post-operative radiological imaging performed within 48 months. RESULTS Seventy-seven patients underwent a VRAM flap reconstruction of which 60 patients met the inclusion requirements for the study (mean age was 60.3 years [range 26-89]; 31 were male and 29 were female). Eighteen patients underwent an APR and 42 underwent a partial or a complete pelvic exenteration and the majority of them (75.0%) were for rectal cancers. Available imaging was on average 21.6 months post-operatively (IQR 11.8-31.3 months). The donor site hernia rate was 16.7%, and the perineal hernia rate was 3.3%. VRAM flap appeared to have DIEA flow in 98.3% of the patients. CONCLUSION VRAM flap reconstruction of complex pelvic defects remains a robust method of choice in complex pelvic reconstruction with little morbidity.
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Affiliation(s)
- Eric Kim
- Department of plastic and reconstructive surgery, Christchurch hospital.
| | | | | | | | - Frank Frizelle
- Department of general surgery, Christchurch hospital; Department of general surgery, University of Otago Christchurch
| | - Tamara Glyn
- Department of general surgery, Christchurch hospital; Department of general surgery, University of Otago Christchurch
| | - Chris Porter
- Department of plastic and reconstructive surgery, Christchurch hospital
| | - Chris Wakeman
- Department of general surgery, Christchurch hospital; Department of general surgery, University of Otago Christchurch
| | - Terry Creagh
- Department of plastic and reconstructive surgery, Christchurch hospital
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Lasso JM, Pinilla C, Vasquez W, Asencio JM. The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction. Ann Plast Surg 2021; 86:688-694. [PMID: 33346550 DOI: 10.1097/sap.0000000000002571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.
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Affiliation(s)
- Jose M Lasso
- From the Department of Plastic and Reconstructive Surgery
| | - Carmen Pinilla
- From the Department of Plastic and Reconstructive Surgery
| | - Wenceslao Vasquez
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - J M Asencio
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
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Sparenberg S, Sharabiany S, Musters GD, Castano Borrero BM, Hompes R, Lapid O, Tanis PJ. Dorsal approach with tailored partial sacrectomy and gluteal V-Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report. BMC Surg 2021; 21:194. [PMID: 33858387 PMCID: PMC8048185 DOI: 10.1186/s12893-021-01189-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue. Case presentations Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity. Conclusion The dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.
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Affiliation(s)
- Sebastian Sparenberg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Brenda M Castano Borrero
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Oren Lapid
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection. Dis Colon Rectum 2021; 64:429-437. [PMID: 33395136 DOI: 10.1097/dcr.0000000000001844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. OBJECTIVE This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. DESIGN This study is a retrospective chart review. SETTINGS Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. PATIENTS Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. INTERVENTIONS Immediate autologous flap reconstruction was performed after abdominoperineal resection. MAIN OUTCOME MEASURES The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. RESULTS Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. LIMITATIONS This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. CONCLUSIONS In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.
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Sharp O, Kapur S, Shaikh I, Rosich-Medina A, Haywood R. The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study. J Plast Reconstr Aesthet Surg 2021; 74:2654-2663. [PMID: 33952435 DOI: 10.1016/j.bjps.2021.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022]
Abstract
The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.
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Affiliation(s)
- Olivia Sharp
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Sandeep Kapur
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Irshad Shaikh
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Anais Rosich-Medina
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Richard Haywood
- Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK; Department of Anatomy, Norwich Medical School, University of East Anglia, Norwich, UK
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Mukherjee T, Kudchadkar SJ, Sagar J, Gurjar S. Rare case of perforated appendicitis presenting as persistent perineal discharge following laparoscopic abdominoperinal excision of rectum (APER). BMJ Case Rep 2021; 14:e236312. [PMID: 33431529 PMCID: PMC7802731 DOI: 10.1136/bcr-2020-236312] [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] [Accepted: 12/17/2020] [Indexed: 01/13/2023] Open
Abstract
Abdominoperineal excision of rectum (APER) is one of the widely used surgical procedures to treat low rectal cancer, benign conditions like Crohn's proctitis with anal involvement and as a salvage procedure for anal cancer. Perineal wound infection is a well-recognised complication following such major surgery. Occurrence of appendicitis in a few weeks' time following such a major surgery is uncommon. However, here we present a rare case report of perforated appendicitis presenting as persistent perineal discharge in an elderly man, following laparoscopic APER for a low rectal tumour. To our knowledge, this is the first time such a rare clinical presentation of appendicitis is reported in the history of medical literature. Through this case report, we aim to highlight the importance of considering such an uncommon presentation in patients with perineal discharge, following APER.
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Affiliation(s)
- Tanmoy Mukherjee
- General Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Jayesh Sagar
- General Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - Shashank Gurjar
- General Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
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20
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Sasaki K, Yoshimi F, Kawasaki H, Hayashi H, Hiyoshi M, Nagai H, Ishihara S. Usefulness of the gracilis muscle flap for reconstruction of large perineal defects following total pelvic exenteration with sacrectomy. ANZ J Surg 2021; 91:1932-1934. [PMID: 33405309 DOI: 10.1111/ans.16566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Fuyo Yoshimi
- Department of Surgery, Ibaraki Prefectural Central Hospital, Ibaraki, Japan
| | - Hiroshi Kawasaki
- Department of Surgery, Ibaraki Prefectural Central Hospital, Ibaraki, Japan
| | - Hiroshi Hayashi
- Department of Orthopedic Surgery, Ibaraki Prefectural Central Hospital, Ibaraki, Japan
| | - Masaya Hiyoshi
- Department of Surgery, Ibaraki Prefectural Central Hospital, Ibaraki, Japan
| | - Hideo Nagai
- Department of Surgery, Ibaraki Prefectural Central Hospital, Ibaraki, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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21
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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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22
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Schellerer VS, Bartholomé L, Langheinrich MC, Grützmann R, Horch RE, Merkel S, Weber K. Donor Site Morbidity of Patients Receiving Vertical Rectus Abdominis Myocutaneous Flap for Perineal, Vaginal or Inguinal Reconstruction. World J Surg 2020; 45:132-140. [PMID: 32995931 PMCID: PMC7752873 DOI: 10.1007/s00268-020-05788-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 12/20/2022]
Abstract
Background Management of donor site closure after harvesting a vertical rectus abdominis myocutaneous (VRAM) flap is discussed heterogeneously in the literature. We aim to analyze the postoperative complications of the donor site depending on the closure technique. Methods During a 12-year period (2003–2015), 192 patients in our department received transpelvic VRAM flap reconstruction. Prospectively collected data were analyzed retrospectively. Results 182 patients received a VRAM flap reconstruction for malignant, 10 patients for benign disease. The median age of patients was 62 years. 117 patients (61%) received a reconstruction of donor site by Vypro® mesh, 46 patients (24%) by Vicryl® mesh, 23 patients (12%) by direct closure and 6 patients (3%) by combination of different meshes. 32 patients (17%) developed in total 34 postoperative complications at the donor site. 22 complications (11%) were treated conservatively, 12 (6%) surgically. 17 patients (9%) developed incisional hernia during follow-up, with highest incidence in the Vicryl® group (n = 8; 17%) and lowest in the Vypro® group (n = 7; 6%). Postoperative parastomal hernias were found in 30 patients (16%) including three patients with simultaneous hernia around an urostomy and a colostomy. The highest incidence of parastomal hernia was found in patients receiving primary closure of the donor site (n = 6; 26%), the lowest incidence in the Vypro® group (n = 16; 14%). Conclusion The use of Vypro® mesh for donor site closure appears to be associated with a low postoperative incidence of complications and can therefore be recommended as a preferred technique.
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Affiliation(s)
- Vera S Schellerer
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany.
| | - Lenka Bartholomé
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Melanie C Langheinrich
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
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Abstract
INTRODUCTION As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits. TECHNIQUE After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect. RESULTS After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap. CONCLUSIONS This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
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Nichols DS, Satteson E, Harbor P, DeFranzo A, David L, Thompson JT. Factors associated with the use of vertical rectus abdominus myocutaneous flap reconstruction following abdominoperineal resection for anorectal cancer. J Surg Oncol 2020; 122:923-927. [PMID: 32596855 DOI: 10.1002/jso.26086] [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: 04/16/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Following abdominoperineal resection (APR), primary closure of the perineal defect is often possible. Some patients, however, require flap reconstruction. Identifying these patients preoperatively is critical to facilitate comprehensive patient counseling and optimize surgical efficacy. METHODS A retrospective review of patients undergoing APR over a 10-year period was performed to identify predictive factors for patients requiring reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap as opposed to primary closure. Student's t and Fisher's exact tests were utilized for statistical analysis. RESULTS A total of 158 patients underwent APR, 29 of whom (18%) required a VRAM flap. A higher average skin resection area was seen among those requiring flap reconstruction (P < .0001). Flap reconstruction was also associated with current smoking status (P = .0197), anal tumor location (P < .0001), and neoadjuvant radiation (P = .0457). Although not statistically significant, average tumor diameter was larger in the VRAM flap group compared with the primary closure group. CONCLUSIONS While the appropriate method of closure for those undergoing APR should be considered on an individual case basis, patients who smoke, have a tumor located at the anus, or require large skin resection are more likely to need flap reconstruction.
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Affiliation(s)
- David S Nichols
- University of Florida College of Medicine, Gainesville, Florida
| | - Ellen Satteson
- University of Florida College of Medicine, Gainesville, Florida.,Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Florida
| | - Patrick Harbor
- Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia
| | - Anthony DeFranzo
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lisa David
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - James T Thompson
- Section of Plastic and Reconstructive Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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25
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Thiele JR, Weber J, Neeff HP, Manegold P, Fichtner-Feigl S, Stark GB, Eisenhardt SU. Reconstruction of Perineal Defects: A Comparison of the Myocutaneous Gracilis and the Gluteal Fold Flap in Interdisciplinary Anorectal Tumor Resection. Front Oncol 2020; 10:668. [PMID: 32435617 PMCID: PMC7218107 DOI: 10.3389/fonc.2020.00668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 04/09/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction: Resection of anorectal malignancies may result in extensive perineal/pelvic defects that require an interdisciplinary surgical approach involving reconstructive surgery. The myocutaneous gracilis flap (MGF) and the gluteal fold flap (GFF) are common options for defect coverage in this area. Here we report our experience with the MGF/GFF and compare the outcome regarding clinical key parameters. Methods: In a retrospective chart review, we collected data from the Department of Plastic Surgery of the University of Freiburg from December 2008–18 focusing on epidemiological, oncological, and therapy-related data including comorbidities (ASA Classification) and peri-/postoperative complications (Clavien-Dindo-System). Results: Twenty-nine patients were included with a mean follow-up of 17 months. Of the cases, 19 (65.5%) presented with recurrent disease, 21 (72.4%) received radiochemotherapy preoperatively, 2 (6.9%) received chemotherapy alone. Microscopic tumor free margins were achieved in 25 cases (86.2%). 17 patients (7 men, 10 women, rectal adenocarcinoma n = 11; anal squamous cell carcinoma n = 6; mean age 58.5 ± 10.68, mean BMI 23.1, mean ASA score 2.8) received a MGF (unilateral n = 10; bilateral n = 7). Twelve patients (7 men, 5 women, rectal adenocarcinoma n = 7; anal squamous cell carcinoma n = 4, proctodeal gland carcinoma n = 1, mean age 66.2 ± 9.2, mean BMI 23.6, mean ASA score 2.6) received coverage with a GFF (unilateral n = 4; bilateral n = 8). Mean operation time of coverage was 105 ± 9 min for unilateral and 163 ± 11 for bilateral MGFs, 70 ± 13 min for unilateral and 107 ± 14 for bilateral GFFs. Complications affected 62%. There was no significant difference in the complication rate between the MGF- and GFF-group. Complications were mainly wound healing disorders that did not extend the hospital stay. No flap loss and no complication that lead to long-lasting disability was documented (both groups). Pain-free sitting took more time in the GFF-group due to the location of the donor site. Conclusion: MG-flaps and GF-flaps prove to be reliable and robust techniques for perineal/pelvic reconstruction. Though flap elevation is significantly faster for GF-flaps, preoperative planning and intraoperative Doppler confirmation are advisable. With comparable complication rates, we suggest a decision-making based on distribution of adipose tissue for dead space obliteration, intraoperative patient positioning, and perforator vessel quality/distribution.
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Affiliation(s)
- Jan R Thiele
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Janick Weber
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Hannes P Neeff
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Philipp Manegold
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
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26
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Proctor MJ, Westwood DA, Donahoe S, Chauhan A, Lynch AC, Heriot AG, Sent-Doux K, Creagh T, Frizelle FA, Wakeman CJ. Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery. Colorectal Dis 2020; 22:562-568. [PMID: 31713965 DOI: 10.1111/codi.14909] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023]
Abstract
AIM Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery. METHOD A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres. RESULTS In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001). CONCLUSION Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.
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Affiliation(s)
- M J Proctor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - D A Westwood
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - S Donahoe
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A Chauhan
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A C Lynch
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A G Heriot
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - K Sent-Doux
- Department of Plastic and Reconstructive Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - T Creagh
- Department of Plastic and Reconstructive Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - F A Frizelle
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,University Department of Surgery, University of Otago, Christchurch, New Zealand
| | - C J Wakeman
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,University Department of Surgery, University of Otago, Christchurch, New Zealand
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27
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Preetha Rani K, Satish Kumar J, Singaravelu V, Deyonna F. Gracilis Myocutaneous Flap: Adding to the Armamentarium of Complex Sacrococcygeal Defect Reconstruction. Indian J Plast Surg 2019; 52:246-249. [PMID: 31602144 PMCID: PMC6785342 DOI: 10.1055/s-0039-1696078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background With increasing radicality of rectal cancer surgeries, the postoperative defects are becoming more complex. This demands an ideal reconstructive option with minimal morbidity to the patient. Although vertical rectus abdominis myocutaneous (VRAM) flap is the commonly used flap, gracilis myocutaneous flap is increasingly being performed to avoid morbidity associated with VRAM flap. Results We share our experience about two of our patients treated for rectal malignancy with pelvic exenteration who were reconstructed immediately with pedicled gracilis myocutaneous flap. Both the patients had an uneventful postoperative recovery period and were discharged on postoperative day 10. During follow-up period both patients had a healthy flap with no evidence of recurrence. No perineal hernias or gross dehiscence of skin closure occurred. Conclusion Gracilis myocutaneous flap has its own place with unique advantages adding to the armamentarium of reconstructive options for complex perineal defects, thereby avoiding the morbidity associated with VRAM flap. It stands as a reliable alternative in patients where VRAM cannot be used.
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Affiliation(s)
- K Preetha Rani
- Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education & Research, Porur, Chennai 600116, Tamil Nadu, India
| | - J Satish Kumar
- Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education & Research, Porur, Chennai 600116, Tamil Nadu, India
| | - V Singaravelu
- Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education & Research, Porur, Chennai 600116, Tamil Nadu, India
| | - Fernandes Deyonna
- Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education & Research, Porur, Chennai 600116, Tamil Nadu, India
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28
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Chen I, Glasgow SC. The technical aspects of rectal cancer surgery. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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29
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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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30
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Ciudad P, Huang TC, Manrique OJ, Agko M, Sapountzis S, Nicoli F, Diya Sabbagh M, Pont LP, Moran SL, Chen H. Expanding the applications of the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for extensive defects. Microsurgery 2018; 39:316-325. [DOI: 10.1002/micr.30413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 11/18/2018] [Accepted: 11/27/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic SurgeryNational Cancer Institute of Peru (INEN) Lima Peru
- Department of Plastic and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | | | - Oscar J. Manrique
- Division of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of GeorgiaAugusta University Augusta Georgia
| | - Stamatis Sapountzis
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Fabio Nicoli
- University of Tor VergataPlastic and Reconstructive Surgery Rome Italy
| | - M. Diya Sabbagh
- Division of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Luis Parra Pont
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Steven L. Moran
- Division of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Hung‐Chi Chen
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
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31
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Perineal Closure after Abdominoperineal Resection Using a Pedicled Deep Inferior Epigastric Perforator Flap: A Safe Alternative to Rectus Abdominis Myocutaneous Flap. J Am Coll Surg 2018; 227:e1-e4. [DOI: 10.1016/j.jamcollsurg.2018.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 12/28/2022]
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32
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Abstract
Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.
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Affiliation(s)
- Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paris Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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33
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Woodfield J, Hulme-Moir M, Ly J. A comparison of the cost of primary closure or rectus abdominis myocutaneous flap closure of the perineum after abdominoperineal excision. Colorectal Dis 2017; 19:934-941. [PMID: 28436214 DOI: 10.1111/codi.13690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/30/2017] [Indexed: 12/13/2022]
Abstract
AIM Perineal wound complications following abdominoperineal resection continue to be a major challenge. The aim of this study was to compare the clinical outcomes and cost of primary closure (PC) and rectus abdominis myocutaneous (RAM) flap reconstruction. METHOD This was a retrospective case review of consecutive patients by one surgeon over 11 years. Patient demographics, risk factors, operative details and complications were identified. Inpatient and outpatient costs were calculated. RESULTS A total of 31 patients underwent a RAM reconstruction and 37 a PC. There were no significant differences in the incidence of wound complications or in the overall costs for either method of perineal closure. When there were no complications the mean costs were significantly higher in the RAM group ($20 948 vs $17 189, P = 0.005), mainly because of the longer operating time. However, the costs of perineal wound complications were greater in the PC group (8394 vs 25 911, P = 0.012). These wounds took longer to heal (median 2 months vs 5.5 months, P = 0.005) and more often required a further reconstructive surgical procedure (RAM 0 vs PC 8, P = 0.006). CONCLUSION This is the first study reporting on the cost implications of PC and RAM flap reconstruction. The overall costs were similar. This implies appropriate clinical selection when choosing between procedures. While the RAM flap is more expensive to perform, the finding that it decreases the clinical severity and cost of perineal wound complications supports its use when there is a high risk of perineal wound complications.
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Affiliation(s)
- J Woodfield
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - M Hulme-Moir
- Department of Surgery, North Shore Hospital, Waitakere District Health Board, Auckland, New Zealand
| | - J Ly
- Department of Surgery, North Shore Hospital, Waitakere District Health Board, Auckland, New Zealand
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34
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Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects. Dis Colon Rectum 2017; 60:945-953. [PMID: 28796733 DOI: 10.1097/dcr.0000000000000875] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN This was a prospective case series. SETTINGS This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured. RESULTS The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.
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Defining the Anatomy of the Tendinous Intersections of the Rectus Abdominis Muscle and Their Clinical Implications in Functional Muscle Neurotization. Ann Plast Surg 2017; 80:50-53. [PMID: 28671887 DOI: 10.1097/sap.0000000000001193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Little is known about the definitive course of the tendinous intersections from anterior to posterior through the rectus abdominis (RA) muscle. The implications of a full thickness intersection may have effects on the ability to neurotize the RA. We hypothesized that these tendinous inscriptions would be fully adherent to the anterior rectus sheath, but there would be an incomplete penetrance into the posterior surface, thereby allowing for muscle fibers and neurovascular structures to run the entire course of the RA muscle. METHODS Fifty-five cadaveric, hemiabdominal walls were evaluated. Measurements were taken of RA muscle thickness, depth of penetrance of the tendinous intersections, and intersection thickness. RESULTS Of the 32 cadavers, 2 had 4 paired tendinous intersections and the remaining 30 cadavers had 3 paired tendinous intersections. Rectus abdominis muscle belly tended to be thicker at midbelly, between intersections than at the level of the corresponding intersection. A total of 168 tendinous intersections were assessed. Thirty (18%) of these inscriptions proved to be full thickness extending from anterior rectus sheath to posterior rectus sheath without any intervening muscle or neurovascular structures. Twenty-three (42%) of the 55 hemiabdomens assessed had at least one full-thickness tendinous intersection. CONCLUSIONS The majority of RA muscles have 3 paired tendinous intersections. Most intersections are incomplete and only encompass the anterior rectus sheath. However, there may be a higher percentage of full-thickness intersections than previously appreciated and the clinical relevance behind these remains unclear.
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Vertical Rectus Abdominis Myocutaneous Versus Alternative Flaps for Perineal Repair After Abdominoperineal Excision of the Rectum in the Era of Laparoscopic Surgery. Ann Plast Surg 2017; 79:101-106. [DOI: 10.1097/sap.0000000000001137] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Schiltz B, Buchs NC, Penna M, Scarpa CR, Liot E, Morel P, Ris F. Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: A review. World J Clin Oncol 2017; 8:249-254. [PMID: 28638794 PMCID: PMC5465014 DOI: 10.5306/wjco.v8.i3.249] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/12/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds. Such large wounds are prone to infection and perineal herniation, and their closure is a major concern to most surgeons. Different approaches to the perineal repair exist, varying from primary or mesh closure to myocutaneous flaps. Each technique has its own associated advantages and potential complications and the ideal approach is still debated. In the present study, we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure. Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction. In addition, the rate of perineal hernia is lower in early follow-up, while long-term hernia occurrence appears to be similar between the different techniques. Finally, it is an easy and quick reconstruction method. Although more expensive than primary closure, the cost associated with the use of a biological mesh is at least equal, if not less, than flap reconstruction.
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Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2016; 137:1602-1613. [PMID: 26796372 DOI: 10.1097/prs.0000000000002107] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications. METHODS A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure. RESULTS Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Singh M, Kinsley S, Huang A, Ricci JA, Clancy TE, Irani J, Goldberg J, Breen E, Bleday R, Talbot SG. Gracilis Flap Reconstruction of the Perineum: An Outcomes Analysis. J Am Coll Surg 2016; 223:602-10. [DOI: 10.1016/j.jamcollsurg.2016.06.383] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/16/2016] [Accepted: 06/23/2016] [Indexed: 11/15/2022]
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Peirce C, Martin S. Management of the Perineal Defect after Abdominoperineal Excision. Clin Colon Rectal Surg 2016; 29:160-7. [PMID: 27247542 PMCID: PMC4882185 DOI: 10.1055/s-0036-1580627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.
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Affiliation(s)
- Colin Peirce
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Sean Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Abdominoperineal resection and perineal wound healing in recurrent, persistent, or primary anal carcinoma. Int J Colorectal Dis 2016; 31:1197-203. [PMID: 27033699 DOI: 10.1007/s00384-016-2575-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Chemoradiotherapy is the standard treatment for squamous cell anal cancer. Salvage abdominoperineal resection (APR) is usually reserved for patients presenting with recurrent or persistent disease. Aim of our study was to review the outcomes of salvage surgery and perineal wound healing with or without a vertical rectus abdominis myocutaneous (VRAM) flap in a single institution over a 6-year period. METHODS Data of all patients with biopsy-proven squamous cell anal cancer treated with chemoradiation at the University Medical Center Mannheim were recorded prospectively. Medical records of all patients who underwent salvage surgery for anal carcinoma between June 2008 and June 2014 were reviewed with regard to surgical and oncological outcomes. RESULTS One hundred twenty-four patients received chemoradiation with a 5-year overall survival of 79 %. Seventeen patients required (salvage) APR for recurrent (n = 8), persistent (n = 7), or primary anal carcinoma (n = 2). Median overall survival was 33.4 months. Median duration until completion of perineal wound healing was shorter in the VRAM group (17 vs. 24.5 weeks; p = 0.0541). CONCLUSIONS Salvage APR has a reasonable chance of long-time survival. Perineal reconstruction with a VRAM flap may reduce the duration until completion of perineal wound healing.
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di Summa PG, Matter M, Kalbermatten DF, Bauquis O, Raffoul W. Transabdominal–pelvic–perineal (TAPP) anterolateral thigh flap: A new reconstructive technique for complex defects following extended abdominoperineal resection. J Plast Reconstr Aesthet Surg 2016; 69:359-67. [DOI: 10.1016/j.bjps.2015.10.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/07/2015] [Accepted: 10/25/2015] [Indexed: 10/22/2022]
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Garofalo F, di Summa PG, Christoforidis D, Pracht M, Laudato P, Cherix S, Bouchaab H, Raffoul W, Demartines N, Matter M. Multidisciplinary approach of lumbo-sacral chordoma: From oncological treatment to reconstructive surgery. J Surg Oncol 2015; 112:544-554. [DOI: 10.1002/jso.24026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Fabio Garofalo
- Department of Visceral Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Pietro G. di Summa
- Department of Plastic and Reconstructive Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Dimitrios Christoforidis
- Department of Visceral Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
- Department of Surgery; Hospital Civico; Lugano Switzerland
| | - Marc Pracht
- Department of Oncology; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Pietro Laudato
- Department of Orthopedics; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Stéphane Cherix
- Department of Orthopedics; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Hanan Bouchaab
- Department of Radio-Oncology; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Wassim Raffoul
- Department of Plastic and Reconstructive Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Maurice Matter
- Department of Visceral Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
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Bruketa T, Majerovic M, Augustin G. Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options. World J Gastroenterol 2015; 21:9002-9020. [PMID: 26290629 PMCID: PMC4533034 DOI: 10.3748/wjg.v21.i30.9002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/08/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023] Open
Abstract
Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.
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Chong TW, Balch GC, Kehoe SM, Margulis V, Saint-Cyr M. Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps. Ann Surg Oncol 2015; 22:3738-44. [DOI: 10.1245/s10434-015-4435-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Indexed: 11/18/2022]
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Elawa S, Hallböök O, Myrelid P, Zdolsek J. Intestinal obstruction following harvest of VRAM-flap for reconstruction of a large perineal defect. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2015; 2:88-91. [PMID: 27252980 PMCID: PMC4793787 DOI: 10.3109/23320885.2015.1102640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
A patient with locally advanced adenocarcinoma of the rectum was operated with abdominoperineal resection and perineal reconstruction with a vertical rectus abdominis musculocutaneous flap. Six days postoperatively, there was herniation of the small bowel, between the anterior and posterior rectus sheaths, to a subcutaneous location.
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Affiliation(s)
- Sherif Elawa
- Department of Hand Surgery, Plastic Surgery and Burns and
| | | | | | - Johann Zdolsek
- Department of Hand Surgery, Plastic Surgery and Burns and
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Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and groin reconstruction. Plast Reconstr Surg 2014; 134:315-323. [PMID: 25068330 DOI: 10.1097/prs.0000000000000324] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications. METHODS All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables. RESULTS There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups. CONCLUSIONS Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Maricevich M, Maricevich R, Chim H, Moran SL, Rose PS, Mardini S. Reconstruction following partial and total sacrectomy defects: An analysis of outcomes and complications. J Plast Reconstr Aesthet Surg 2014; 67:1257-66. [DOI: 10.1016/j.bjps.2014.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 03/16/2014] [Accepted: 05/03/2014] [Indexed: 10/25/2022]
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Hydrogen peroxide priming of the venous architecture: a new technique that reveals the underlying anatomical basis for venous complications of DIEP, TRAM, and other abdominal flaps. Plast Reconstr Surg 2014; 133:790e-804e. [PMID: 24569423 DOI: 10.1097/prs.0000000000000228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies of venous anatomy lack the detail of their arterial counterparts because of (1) the technical challenge of retrograde perfusion against competent valves and (2) anterograde venous perfusion failing to adequately delineate the area of interest. We introduced a novel technique: retrograde hydrogen peroxide priming that dilates veins and renders valves incompetent, thereby facilitating complete cadaveric venous perfusion. METHODS The superficial and deep venous systems of 41 hemiabdomens and 20 hemichests of unembalmed human cadavers were primed by retrograde injection with 6% hydrogen peroxide. Specimens were then injected with lead oxide contrast, radiographed, and dissected. In five hemiabdomens, the valves were mapped by dissection. Results were compared with archival venous studies of six total body injections, six abdominal lipectomy specimens, and two intraoperative venograms of delayed transverse rectus abdominis musculocutaneous flaps. RESULTS Unprecedented venous filling of the anterior torso was demonstrated. Two types of superficial-to-deep venous connections were defined: large venae communicantes and small venae comitantes. Venae communicantes (>2 mm) formed major connections between large superficial and deep veins, mostly within 5 cm of the umbilicus in the abdomen, the axilla and fifth or sixth intercostal space parasternally. Seventy-four percent of venae communicantes coursed with arteries greater than 1.0 mm. Four major longitudinal valved subcutaneous pathways of the superficial inferior epigastric vein and superficial circumflex iliac vein were defined bilaterally with large avalvular transverse connections in the midline and small-caliber connections laterally that explain venous complications seen sometimes in transverse abdominal flaps. CONCLUSION Retrograde hydrogen peroxide priming of veins in cadavers renders valves incompetent and facilitates detailed venous studies that help refine flap design and explain venous complications.
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Garofalo F, Christoforidis D, di Summa PG, Gay B, Cherix S, Raffoul W, Demartines N, Matter M. The unresolved case of sacral chordoma: from misdiagnosis to challenging surgery and medical therapy resistance. Ann Coloproctol 2014; 30:122-31. [PMID: 24999463 PMCID: PMC4079810 DOI: 10.3393/ac.2014.30.3.122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 10/18/2013] [Indexed: 01/16/2023] Open
Abstract
PURPOSE A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status. METHODS Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension. RESULTS Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years). CONCLUSION Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center.
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Affiliation(s)
- Fabio Garofalo
- Department of Surgery, Intercantonal Hospital Broye, Payerne, Switzerland. ; Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Dimitrios Christoforidis
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland. ; Department of Surgery, Hospital Civico, Lugano, Switzerland
| | - Pietro G di Summa
- Department of Plastic and Reconstructive Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Béatrice Gay
- Department of Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Stéphane Cherix
- Department of Orthopedics, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Wassim Raffoul
- Department of Plastic and Reconstructive Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Maurice Matter
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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