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Bhama AR, Maykel JA. Diagnosis and Management of Chronic Anastomotic Leak. Clin Colon Rectal Surg 2021; 34:406-411. [PMID: 34853562 DOI: 10.1055/s-0041-1732322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.
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Affiliation(s)
- Anuradha R Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Wooster, Massachusetts
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Assi H, Persson A, Palmquist I, Öberg M, Buchwald P, Lydrup ML. Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study. Eur J Surg Oncol 2021; 48:1161-1166. [PMID: 34794841 DOI: 10.1016/j.ejso.2021.11.001] [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: 06/07/2021] [Revised: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. METHOD This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. RESULTS One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. CONCLUSION bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.
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Affiliation(s)
- Hanin Assi
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Anna Persson
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Ingrid Palmquist
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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Inferior Part of Rectus Abdominis Muscle Flap Outcomes after Abdominoperineal Resection: A Case Series Pilot Study. World J Plast Surg 2021. [DOI: 10.52547/wjps.10.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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4
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Van Vliet A, Girardot A, Bouchez J, Bigness A, Wang K, Moino D, Theodotou A, Pothuraju T, Felder S, Smith P, Kumar A, Dayicioglu D. How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction. Ann Plast Surg 2021; 86:S571-S574. [PMID: 34100815 DOI: 10.1097/sap.0000000000002875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. METHODS A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. RESULTS There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). CONCLUSIONS The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.
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Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods. Plast Reconstr Surg 2021; 147:1420-1435. [PMID: 33973948 DOI: 10.1097/prs.0000000000007976] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. METHODS A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. RESULTS The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. CONCLUSIONS Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.
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Copeland-Halperin LR, Stewart T, Chen Y, Funderburk CD, Freed GL. Perineal reconstruction following abdominoperineal resection: Comprehensive review of the literature. J Plast Reconstr Aesthet Surg 2020; 73:1924-1932. [DOI: 10.1016/j.bjps.2020.08.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/24/2020] [Indexed: 12/12/2022]
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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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Horch RE, Ludolph I, Cai A, Weber K, Grützmann R, Arkudas A. Interdisciplinary Surgical Approaches in Vaginal and Perineal Reconstruction of Advanced Rectal and Anal Female Cancer Patients. Front Oncol 2020; 10:719. [PMID: 32477947 PMCID: PMC7237715 DOI: 10.3389/fonc.2020.00719] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022] Open
Abstract
Relapsing or far advanced rectal and anal cancers remain difficult to treat and require interdisciplinary approaches. Due to modern standard protocols all patients receive irradiation and neoadjuvant chemotherapy-and in case of a relapse a second irradiation-rendering the surgical site prone to surgical site infections and oftentimes long lasting sinus and septic complications after exenteration in the pelvis. Despite an improved overall survival rate in these patients the downside of radical tumor surgery in the pelvis is a major loss of quality of life, especially in women when parts of the vagina need to be resected. Derived from our experince with over 300 patients receiving pelvic and perineal reconstruciton with a transpelvic vertical rectus abdominis myocutaneous (tpVRAM) flap we studied the impact of this surgical technique on the outcomes of female patients with or without vaginal reconstruction following pelvic exenteration. We found out that the tpVRAM flap is reliably perfused and helps to reduce long term wound healing desasters in the irradiated perineal/vaginal/gluteal region.
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Affiliation(s)
- Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Aijia Cai
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
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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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Leeds IL, Taylor JP, Pozo M, Safar B, Sacks JM, Fang SH. Gracilis Flap for Perineal Closures in Minimally Invasive Abdominoperineal Resection. Am Surg 2017. [DOI: 10.1177/000313481708300606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ira L. Leeds
- Department of Surgery Johns Hopkins University School of Medicine Baltimore, Maryland
| | - James P. Taylor
- Department of Surgery Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Marcos Pozo
- Department of Surgery Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Justin M. Sacks
- Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Sandy H. Fang
- Department of Surgery Johns Hopkins University School of Medicine Baltimore, Maryland
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Althumairi AA, Canner JK, Ahuja N, Sacks JM, Safar B, Efron JE. Time to Chemotherapy After Abdominoperineal Resection: Comparison Between Primary Closure and Perineal Flap Reconstruction. World J Surg 2016; 40:225-30. [PMID: 26336877 DOI: 10.1007/s00268-015-3224-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Wound complications are frequent flowing abdominoperineal resection (APR); this can lengthen the time to chemotherapy. Flap reconstruction is being used in an attempt to improve wound healing. OBJECTIVES To assess the effect of flap reconstruction after APR on time to perineal wound healing and administration of adjuvant chemotherapy in patients with rectal adenocarcinoma. METHODS A retrospective review of patients who underwent APR for rectal adenocarcinoma between 2002 and 2012 was performed. Patients were divided into two groups based on type of perineal wound closure (primary vs. flap). Patients were compared for time to perineal wound healing, and time to adjuvant chemotherapy. RESULTS 115 patients were identified; of whom 67 received adjuvant chemotherapy. 56 (84%) patients underwent primary closure while 11 (16%) underwent flap reconstruction. There was no difference in time to perineal wound healing (6.8 vs. 6.3 weeks, p = 0.40) and time to receive adjuvant chemotherapy (9.3 vs. 10.7 weeks, p = 0.79) between the primary closure and flap reconstruction groups, respectively. 25 (45%) of the primary closure group had a delay in receiving adjuvant chemotherapy versus 6 (55%) of the flap reconstruction group (p = 0.55). Delay in receiving adjuvant chemotherapy because of perineal wound complications occurred in 18 (32%) patients with primary closure versus 3 (28%) patients with flap reconstruction (p = 0.14). CONCLUSIONS Flap reconstruction does not reduce the length of time to initiating chemotherapy; there was no difference in length of healing between the two groups. Therefore, flap reconstruction should be selectively used based on the size of the perineal defect.
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Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Althumairi AA, Canner JK, Gearhart SL, Safar B, Fang SH, Wick EC, Efron JE. Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 2016; 18:O260-6. [PMID: 27178168 DOI: 10.1111/codi.13384] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/24/2016] [Indexed: 02/08/2023]
Abstract
AIM The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.
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Affiliation(s)
- A A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - E C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Predictors of wound dehiscence and its impact on mortality after abdominoperineal resection: data from the National Surgical Quality Improvement Program. Tech Coloproctol 2016; 20:475-82. [DOI: 10.1007/s10151-016-1486-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
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Gravante G, Miah A, Mann CD, Stephenson JA, Gani MAD, Sharpe D, Norwood M, Boyle K, Miller A, Hemingway D. Circumferential resection margins and perineal complications after neoadjuvant long-course chemoradiotherapy followed by extralevator abdominoperineal excision of the rectum: Five years of activity at a single institution. J Surg Oncol 2016; 114:86-90. [PMID: 27076410 DOI: 10.1002/jso.24257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/26/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prone extralevator abdominoperineal excision of the rectum (ELAPE) has been introduced to improve the circumferential resection margins (CRM) compared with traditional APER. OBJECTIVE We present short-term results achieved with prone ELAPE preceded by neoadjuvant chemoradiotherapy during the last 5 years of activity. DESIGN A retrospective review was conducted. SETTINGS AND PATIENTS Prone ELAPE operations performed between September 2010 and August 2014 at Leicester Royal Infirmary preceded by neoadjuvant chemoradiotherapy. INTERVENTIONS AND MAIN OUTCOME MEASURES Data regarding demographics, staging, neoadjuvant therapies, intraoperative perforations, and perineal complications were collected. RESULTS Seventy-two patients were included. Pretreatment radiological T4 were 25.0%, histological T4 2.8%. Intraoperative perforations occurred in 2.8%, CRM was involved in 11.1%. Perineal complications consisted of superficial wound infections (20.8%), full thickness dehiscences (16.7%), hematomas (9.7%), pelvic collections (6.9%), and perineal hernias (5.6%). CONCLUSIONS In our experience, prone ELAPE preceded by long-course chemoradiotherapy has been successfully used in the last 5 years to resect low rectal tumors. Perineal wound complications rates are similar to those presented in series using direct perineal closures. J. Surg. Oncol. 2016;114:86-90. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Gianpiero Gravante
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Anur Miah
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Christopher D Mann
- Department of Colorectal Surgery, Leicester General Hospital, Leicester, United Kingdom
| | | | | | - David Sharpe
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Michael Norwood
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Kirsten Boyle
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Andrew Miller
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
| | - David Hemingway
- Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
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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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16
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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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Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology. Gynecol Oncol 2014; 134:172-80. [DOI: 10.1016/j.ygyno.2014.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 04/26/2014] [Accepted: 04/30/2014] [Indexed: 11/23/2022]
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Horch RE, Hohenberger W, Eweida A, Kneser U, Weber K, Arkudas A, Merkel S, Göhl J, Beier JP. A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Colorectal Dis 2014; 29:813-23. [PMID: 24752738 DOI: 10.1007/s00384-014-1868-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps. METHODS Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps. RESULTS In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %. CONCLUSIONS The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.
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Affiliation(s)
- R E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Krankenhausstrasse 12, 91054, Erlangen, Germany,
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Touny A, Othman H, Maamoon S, Ramzy S, Elmarakby H. Perineal reconstruction using pedicled vertical rectus abdominis myocutaneous flap (VRAM). J Surg Oncol 2014; 110:752-7. [DOI: 10.1002/jso.23692] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/21/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Ahmed Touny
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Haitham Othman
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Sherif Maamoon
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Samy Ramzy
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
| | - Hamdy Elmarakby
- Surgical Oncology Department; National Cancer Institute, Cairo University; Fom Elkhalig Cairo Egypt
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O’Dowd V, Burke JP, Condon E, Waldron D, Ajmal N, Deasy J, McNamara DA, Coffey JC. Vertical rectus abdominis myocutaneous flap and quality of life following abdominoperineal excision for rectal cancer: a multi-institutional study. Tech Coloproctol 2014; 18:901-6. [DOI: 10.1007/s10151-014-1156-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 04/12/2014] [Indexed: 11/12/2022]
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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100:E1-33. [PMID: 23901427 DOI: 10.1002/bjs.9192_1] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. METHODS Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. RESULTS The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. CONCLUSION The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.
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Perineal Wound Complications, Risk Factors, and Outcome After Abdominoperineal Resections. Ann Plast Surg 2013; 71:209-13. [DOI: 10.1097/sap.0b013e31823fac2b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Toshniwal S, Perera M, Lloyd D, Nguyen H. A 12-year experience of the Trendelenburg perineal approach for abdominoperineal resection. ANZ J Surg 2013; 83:853-8. [DOI: 10.1111/ans.12137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2013] [Indexed: 01/21/2023]
Affiliation(s)
| | | | - David Lloyd
- Launceston General Hospital; Launceston Tasmania Australia
| | - Hung Nguyen
- Launceston General Hospital; Launceston Tasmania Australia
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Chokshi RJ, Kuhrt MP, Arrese D, Martin EW. Reconstruction of total pelvic exenteration defects with rectus abdominus myocutaneous flaps versus primary closure. Am J Surg 2013; 205:64-70. [DOI: 10.1016/j.amjsurg.2012.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 04/18/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
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Seth R, Khan AA, Pencavel T, Harrington KJ, Harris PA. Targeted gene delivery by free-tissue transfer in oncoplastic reconstruction. Lancet Oncol 2012; 13:e392-402. [DOI: 10.1016/s1470-2045(12)70235-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Dynamic Magnetic Resonance Imaging Demonstrates the Integrity of Perineal Reconstruction following Cylindrical Abdominoperineal Excision with Reconstruction of the Pelvic Floor Using Porcine Collagen. Case Rep Med 2012; 2012:752357. [PMID: 22312372 PMCID: PMC3270543 DOI: 10.1155/2012/752357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/18/2011] [Indexed: 12/13/2022] Open
Abstract
A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. This was confirmed histologically as adenocarcinoma. Radiological staging was consistent with a T3N2 rectal tumour. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease. She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. The perineal defect was reconstructed with Permacol (biological implant, Covidien) mesh. She had no clinical evidence of a perineal hernia at serial followup. Dynamic MRI images of the pelvic floor obtained during valsalva at 10 months revealed an intact pelvic floor. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was also imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision.
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Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg 2011; 128:447-458. [PMID: 21788836 DOI: 10.1097/prs.0b013e31821e6fd2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Reconstruction of irradiated pelvic defects following oncologic resection requires dead-space obliteration to reduce wound healing complications. Although the vertical rectus abdominis myocutaneous (VRAM) flap is often the best option for pelvic reconstruction following abdominoperineal resection or pelvic exenteration, donor- and recipient-site complications are common. The authors hypothesized that certain adjuvant techniques would improve pelvic VRAM flap outcomes. METHODS Six technical modifications to improve VRAM flap outcomes were evaluated: fascia-sparing VRAM flap, component separation donor-site closure, inlay mesh abdominal reinforcement, deepithelialized VRAM flap skin paddle, extended VRAM flap, and omental flap plus VRAM flap. Prospectively collected data from consecutive patients with immediate pelvic VRAM flap reconstruction from 2001 to 2009 were analyzed retrospectively. Donor- and recipient-site complications were compared between patients treated with each technical modification and all other study patients. RESULTS One hundred eighty-five patients were included (mean follow-up, 25.1 months). Fascia-sparing VRAM flaps resulted in significantly fewer hernias (1.5 percent versus 11.5 percent, p < 0.01), with less dehiscence, abdominal bulge, and evisceration. Patients receiving donor-site mesh inlay had fewer postoperative hernias (2.6 percent versus 5.5 percent) but more abdominal laxity/bulge (7.7 percent versus 0 percent, p = 0.01). Minor recipient-site dehiscence was significantly lower with omental plus VRAM flaps (11.1 percent versus 32.5 percent, p < 0.05) and extended VRAM flaps (7.7 percent versus 30.8 percent, p < 0.05). Multivariate logistic regression identified omental plus VRAM flaps as protective against (p < 0.05), and increasing body mass index as predictive for (p = 0.009), perineal skin dehiscence. CONCLUSIONS Several technical modifications of VRAM flap reconstruction improve pelvic reconstruction outcomes and should be considered. Further prospective studies will be important to elucidate specific indications for each technique.
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Daigeler A, Simidjiiska-Belyaeva M, Drücke D, Goertz O, Hirsch T, Soimaru C, Lehnhardt M, Steinau HU. The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg 2011; 396:1271-9. [PMID: 21779830 DOI: 10.1007/s00423-011-0823-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 06/23/2011] [Indexed: 12/01/2022]
Abstract
PURPOSE The vertical rectus abdominis muscle (VRAM) flap is considered a safe and simple option to cover defects of the trunk and proximal thigh. Detailed long-time follow-up studies in oncologic patients including complications and donor site morbidity are rare. In this study, complications and donor site morbidity were analysed. METHODS Data of 78 consecutive patients with oncologic disease, having received VRAM flaps, were analysed retrospectively. Patients with soft tissue sarcomas (n = 38), radiation ulcers (n = 18), carcinoma (n = 10), wound-healing difficulties after tumour resection (n = 8), breast reconstruction after ablation (n = 3) and malignant melanoma (n = 1) were included. Statistics concerning patients' satisfaction, the occurrence of wound-healing difficulties, incisional herniation, loss of abdominal wall strength in correlation to operative and (neo)adjuvant treatment and patients' history were performed. The mean follow-up time was 5.5 years. RESULTS No complete flap loss was observed. A body mass index over 30 was positively correlated with wound-healing difficulties; radiation had no negative effect. A contralateral cutaneous pedicle could reduce the risk of lymphoedema in groin defect patients. Incisional hernia was present in 13%. Strength endurance of the abdominal wall was reduced compared to an age-matched control. Most patients were satisfied with the postoperative result. CONCLUSIONS VRAM flaps are reliable tools for defect coverage in the oncologic patient to prevent chronic ulceration, lymphangitis or more severe complications like septic rupture of femoral vessels and hip disarticulation. Donor site morbidity is tolerable, and patients' satisfaction is high.
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Affiliation(s)
- Adrien Daigeler
- Department of Plastic Surgery, Burn Center, Sarcoma Reference Center, BG-University Hospital Bergmannsheil, Buerkle-de-la-Camp-Place 1, 44789, Bochum, Germany.
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Casal Núñez JE, Cáceres Alvarado N, de Sanildefonso Pereira A, Toscano Novelle MÁ, García Martínez MT, Jove Albores P. Resección abdominoperineal en cáncer anal: reconstrucción del periné con colgajo miocutáneo de músculo recto anterior abdominal. Cir Esp 2011; 89:31-6. [DOI: 10.1016/j.ciresp.2010.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 09/28/2010] [Accepted: 10/02/2010] [Indexed: 11/17/2022]
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