Perineal Wound Complications, Risk Factors, and Outcome After Abdominoperineal Resections

System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection

BACKGROUND

Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.

METHODS

Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.

RESULTS

The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).

CONCLUSIONS

Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

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

Background

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

Methods

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

Results

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

Conclusions

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

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects

AIM

Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects.

METHODS

We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal.

RESULTS

Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes.

CONCLUSIONS

The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement

BACKGROUND

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE).

METHODS

A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations.

RESULTS

Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications.

CONCLUSION

This position statement updates clinicians on current evidence around perineal closure after APE surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complexities of abdominoperineal surgery: synchronous resection of an ano-rectal adenocarcinoma and pelvic schwannoma

Abdominoperineal resection (APR) is indicated for low rectal/ano-rectal cancers. It necessitates fastidious pelvic dissection posing certain operative difficulties. We present the surgical challenges in a unique case of a patient presenting with a low rectal adenocarcinoma and a synchronous pelvic schwannomas, both requiring resection. A 71-year-old gentleman presented for surveillance colonoscopy following previous excision of colonic polyps. This investigation revealed a polypoid mass at the ano-rectal junction which was histologically proven as an adenocarcinoma with high-grade dysplasia. A staging computed tomography scan revealed an incidental 10 × 15 cm homogeneous, pre-sacral mass. After meticulous operative planning, the patient underwent successful open resection of this mass and concurrent APR for his low rectal lesion. This case demonstrates a rare presentation of a low rectal adenocarcinoma and concurrent pelvic schwannoma. We discuss the technical difficulties encountered in the management of such complex pelvic tumours and highlight the successful outcomes of the synchronous resection.

Biologic meshes in perineal reconstruction following extra-levator abdominoperineal excision (elAPE)

Recent improvements in the outcome for low rectal cancer have focused on the reconstruction of the perineal defect following greater acceptance of the need for a wider perineal excision encompassing the levator ani complex. In this article we look at the use of biologic materials to close the perineal defect and compare this with the use of other techniques.