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Gielen AHC, Colier E, Qiu SS, Keymeulen KBMI, Stassen LPS, Melenhorst J. Research highlight: surgical outcomes of gluteal VY plasty after extensive abdominoperineal resection or total pelvic exenteration. Langenbecks Arch Surg 2023; 408:157. [PMID: 37088846 PMCID: PMC10123027 DOI: 10.1007/s00423-023-02896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/13/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To describe a suitable alternative technique for reconstruction of the pelvic floor after extensive resection. To review our outcomes of gluteal VY plasty in the reconstruction of the pelvic floor after extensive abdominoperineal resection (conventional or extralevator abdominoperineal resection, total pelvic exenteration, or salvage surgery). DESIGN Retrospective cohort study. SETTING An academic hospital and tertiary referral centre for the treatment of locally advanced or locally recurrent rectal cancer, and salvage surgery in The Netherlands. PATIENTS Forty-one consecutive patients who underwent a pelvic floor reconstruction with gluteal VY plasty at Maastricht University Medical Centre between January 2017 and February 2021 were included. The minimum duration of follow-up was 2 years. MAIN OUTCOME MEASURES Perineal herniation is the primary outcome measure. Furthermore, the occurrence of minor and major postoperative complications and long-term outcomes were retrospectively assessed. RESULTS Thirty-five patients (85.4%) developed one or more complications of whom twenty-one patients experienced minor complications and fourteen patients developed major complications. Fifty-seven percent of complications was not related to the VY reconstruction. Six patients (14.6%) recovered without any postoperative complications during follow-up. Three patients developed a perineal hernia. CONCLUSIONS A gluteal VY plasty is a suitable technique for reconstruction of the pelvic floor after extensive perineal resections resulting in a low perineal hernia rate, albeit the complication rate remains high in this challenging group of patients.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - Evie Colier
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Kristien B M I Keymeulen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands.
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Partial myocutaneous gluteal flap for perineal reconstruction of extralevator abdominoperineal defects. A single surgeon series of 49 cases in 8 years, and a modification of the technique. J Plast Reconstr Aesthet Surg 2021; 75:125-136. [PMID: 34353736 DOI: 10.1016/j.bjps.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 02/03/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Extralevator abdominoperineal excision (ELAPE) for low rectal tumours necessitates a reliable method of reconstructing the perineum. The senior author developed the partial myocutaneous gluteal (PMG) flap. We present 49 consecutive reconstructions with the refinement of the original procedure. METHODS We conducted a retrospective observational review of patients undergoing ELAPE and PMG reconstruction from 2012 to 2019, with at least 1 year follow-up. The procedure was modified iteratively following our original series, to minimise perineal herniation, specifically by greater mobilisation of the inferior gluteus maximus muscle and separation of the muscle and fasciocutaneous components, allowing closure of the defect around the coccygeal remnant. Perineal herniation and wound complications were recorded. Laparoscopic and open resection techniques were compared, as were outcomes before and after modification of the flap. RESULTS There were no flap failures in our cohort of 49 patients. Two patients (4%) required return to theatre acutely for perineal wound complications: one wound dehiscence and one flap-related haematoma. Five patients had evidence of perineal hernia, three prior to any modification of the flap and two following. Three had symptoms of which two required elective repair. The flap modifications were made in response to these cases. There were no significant differences in perineal outcomes for laparoscopic versus open, and before and after flap modification. CONCLUSIONS Over the last 8 years, we have refined our perineal reconstruction technique following instances of perineal herniation and major wound dehiscence. We believe that the PMG flap provides robust and reliable option for the reconstruction of perineal extralevator abdominoperineal defects.
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Elia J, Do NTK, Chang TNJ, Lai CH, Chou HH, Chang FCS, Huang JJ. Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps. J Reconstr Microsurg 2021; 38:10-26. [PMID: 33853124 DOI: 10.1055/s-0041-1727199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. METHODS A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. RESULTS Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. CONCLUSION In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.
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Affiliation(s)
- Jhonatan Elia
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nicholas T K Do
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tommy N-J Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chyong-Huey Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Hung-Hsueh Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Frank C-S Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
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Immediate Perineal Reconstruction After Extralevatory Abdominoperineal Excision: Buried Desepidermised Fasciocutaneous V-Y Advancement Flap. Ann Plast Surg 2018; 80:154-158. [PMID: 29095185 DOI: 10.1097/sap.0000000000001234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND According to National Cancer Institute, there are approximately 39,800 rectal cancer cases per year, 25% of which will need an abdominoperineal resection (APR). The key to avoid most of the complications related to pelvic defect that occurs after APR is choosing an appropriate reconstruction option for perineum. This study aims to introduce an easily applicable flap option for closure to address postoperative pelvic defect in low rectal cancer. METHODS This is a retrospective evaluation of 9 patients who have undergone perineal reconstruction for pelvic defects after extralevatory abdominoperineal excision with rectal cancer between 2014 and 2016. Reconstruction consists of a novel technique defined by our clinic, which is buried desepidermised fasciocutaneous V-Y advancement flap. RESULTS All defects are closed successfully. Patients are followed postoperatively for complications such as perineal infection, wound dehiscence, seroma, perineal sinus, or fistula formation. Flaps are evaluated with magnetic resonance imaging postoperatively, for viability and effectiveness on defect closure. Mean follow-up time is 20 (±9) months. Mean average hospital stay is 8 (±2) days. We did not experience any total or partial flap loss or encounter any local complication related to the wound. CONCLUSIONS Buried desepidermised fasciocutaneous V-Y advancement flap is a reasonably easy and time-saving operation. It is effective in filling the pelvic dead space while closing the sacral defect after APR and therefore decreases late term complications related to large perineal excision.
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Foster JD, Tou S, Curtis NJ, Smart NJ, Acheson A, Maxwell-Armstrong C, Watts A, Singh B, Francis NK. Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement. Colorectal Dis 2018; 20 Suppl 5:5-23. [PMID: 30182511 DOI: 10.1111/codi.14348] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). METHODS A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. RESULTS Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. CONCLUSION This position statement updates clinicians on current evidence around perineal closure after APE surgery.
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Affiliation(s)
- J D Foster
- Department of General Surgery, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
| | - S Tou
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - N J Smart
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - A Acheson
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - C Maxwell-Armstrong
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - A Watts
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - B Singh
- Department of General Surgery, Leicester General Hospital, Leicester, UK
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Ge W, Jiang SS, Qi W, Chen H, Zheng LM, Chen G. Extralevator abdominoperineal excision for rectal cancer with biological mesh for pelvic floor reconstruction. Oncotarget 2018; 8:8818-8824. [PMID: 27732566 PMCID: PMC5352444 DOI: 10.18632/oncotarget.12502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/28/2016] [Indexed: 01/07/2023] Open
Abstract
Goal To share our experience of extra-levator abdominoperineal excision (ELAPE) for low rectal cancer, focusing on perineal repair with biological mesh. Methods We retrospectively analyzed medical records of all patients with low rectal cancer who underwent the ELAPE procedure using biological mesh for perineal repair at the Gastrointestinal Surgery of Nanjing Drum Power Hospital between January 2013 and September 2015. All patients were closely followed up to now. Results A total of 17 patients underwent ELAPE for low rectal cancer was screened. Of these, 15 patients had primary rectal cancer, 1 had local recurrent rectal cancer, and 1 had malignant melanoma. All patients underwent ELAPE successfully without intestinal perforation and got stage I healing in perineum wound without incision infection, dehiscence, cystocele perinealis, urethral dysfunction or intestinal obstruction. Perineum wound hematoma developed in just one patient and had successful percutaneous drainage in one week. During the follow-up, there was no recurrence, perineal hernia, sexual dysfunction, urinary retention, or bowel obstruction. Two patients described slight pain in the sacrococcygeal region without special handling. Conclusion ELAPE is applicable to low rectal cancer. Biological mesh reconstruction of perineal defect seems to be safe and effective, with high patient compliance.
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Affiliation(s)
- Wei Ge
- Department of general surgery, Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, P. R. China
| | - Song-Song Jiang
- Department of general surgery, Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, P. R. China
| | - Wang Qi
- Department of general surgery, Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, P. R. China
| | - Hao Chen
- Department of general surgery, Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, P. R. China
| | - Li-Ming Zheng
- Department of general surgery, Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, P. R. China
| | - Gang Chen
- Department of general surgery, Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, P. R. China
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Sheckter CC, Shakir A, Vo H, Tsai J, Nazerali R, Lee GK. Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience. J Plast Reconstr Aesthet Surg 2016; 69:1506-1512. [DOI: 10.1016/j.bjps.2016.06.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 06/13/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
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