Lotus petal perforator flap for reconstruction of an extended chronic presacral defect after radiotherapy and rectal cancer resection

Combined use of a petal flap and V-Y advancement flap for reconstruction of presacral defects following rectal resection

BACKGROUND

The aim of this study was to evaluate the efficacy of a combination of flaps for the reconstruction of presacral defects following abdominoperineal resections: a paramedian vertically oriented caudally based lotus petal flap for presacral defects combined with a horizontal V-Y advancement flap for closure of the superficial donor site defect.

METHODS

A retrospective study was conducted on patients with a residual defect following an abdominoperineal resection between 2010 and 2017 in the Noordwest Ziekenhuisgroep. The primary endpoint was complications related to the reconstruction.

RESULTS

Twelve patients were included, all reconstructions healed well. Three patients had a grade I or II complication (Clavien Dindo classification).

CONCLUSIONS

Use of a petal flap and V-Y advancement flap for reconstruction of presacral defects was found to be safe and simple, and should, therefore, be considered in the management of such problems.

Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects

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.

Massive perineal defect after radio-chemotherapy

Herein, we present a rare complication of radio-chemotherapy. A young man presented with loss of urine from the posterior perineum that showed a massive disappearance. He underwent Hartmann procedure for rectal neoplasia, afterwards treated with intensity-modulated radiotherapy (IMRT) (until 67 Gy) and chemotherapy with FOLFOX protocol (Leucoverin calcium, Fluorouracil, Oxaliplatin).