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Boccara D, Lefevre JH, Serror K, Chatelain S, Dutot MC, Kaplan J, Mimoun M, Chaouat M, Levy S. Short- and long-term morbidity after Taylor flap (oblique rectus abdominis flap) for perineal reconstruction after abdominoperineal resection: A single-center series of 140 patients. J Plast Reconstr Aesthet Surg 2024; 93:163-169. [PMID: 38696870 DOI: 10.1016/j.bjps.2024.04.037] [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: 08/07/2023] [Revised: 02/17/2024] [Accepted: 04/11/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Abdominoperineal resection (APR) leads to a substantial loss of tissue and a high rate of complications. The Taylor flap is a musculocutaneous flap used in reconstruction after APR. OBJECTIVES We aimed to analyze the short and long-term morbidity of reconstruction with a Taylor flap (oblique rectus abdominis flap) after APR and to identify the risk factors for postoperative complications. METHODS We retrospectively included all patients who had undergone APR with immediate reconstruction with a Taylor flap in our department between July 2000 and June 2018. Demographics, oncological data, treatment, and short- and long-term morbidity were reviewed. RESULTS Among the 140 patients included, we identified early minor complications in 42 patients (30%) and 14 early major complications (10%). Total necrosis of the flap requiring its removal occurred in four patients (2.8%). Eleven patients (7.9%) presented with a midline incision hernia, and seven (5%) presented with a subcostal incision hernia. No perineal hernia was found. No risk factors for the complications were identified. CONCLUSION The Taylor flap is a safe procedure with few complications and limited donor site morbidity. Moreover, it prevents perineal hernias. These results confirm that the Taylor flap is a well-suited procedure for reconstruction after APR.
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Affiliation(s)
- David Boccara
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France.
| | - Jeremie H Lefevre
- Department of General Surgery, Saint Antoine Hospital, Paris, France
| | - Kevin Serror
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | - Sarah Chatelain
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | | | - Jeremy Kaplan
- Division of Gastroenterology, Kingman Regional Medical Center, Kingman, AR, USA
| | - Maurice Mimoun
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | - Marc Chaouat
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | - Samuel Levy
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
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Rosen R, Quezada-Diaz FF, Gönen M, Karagkounis G, Widmar M, Wei IH, Smith JJ, Nash GM, Weiser MR, Paty PB, Cercek A, Romesser PB, Sanchez-Vega F, Adileh M, Roth O’Brien D, Hajj C, Williams VM, Shcherba M, Gu P, Crane C, Saltz LB, Garcia Aguilar J, Pappou E. Oncologic Outcomes of Salvage Abdominoperineal Resection for Anal Squamous Cell Carcinoma Initially Managed with Chemoradiation. J Clin Med 2024; 13:2156. [PMID: 38673429 PMCID: PMC11050212 DOI: 10.3390/jcm13082156] [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: 02/24/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Abdominoperineal resection (APR) has been advocated for persistent or recurrent disease after failure of chemoradiation (CRT) for anal squamous cell cancer (SCC). Treatment with salvage APR can potentially achieve a cure. This study aimed to analyze oncological outcomes for salvage APR in a recent time period at a comprehensive cancer center. Methods: A retrospective review of all patients who underwent APR for biopsy-proven persistent or recurrent anal SCC between 1 January 2007 and 31 December 2020 was performed. Patients with stage IV disease at the time of initial diagnosis and patients with missing data were excluded. Univariate analysis was used with a chi-square test for categorical variables, and non-parametric tests were used for continuous variables. Kaplan-Meier survival analysis was performed to evaluate disease-specific (DSS), post-APR local recurrence-free (RFS), and disease-free survival (DFS). Results: A total of 96 patients were included in the analysis: 39 (41%) with persistent disease and 57 (59%) with recurrent SCC after chemoradiation had been completed. The median follow-up was 22 months (IQR 11-47). Forty-nine patients (51%) underwent extended APR and/or pelvic exenteration. Eight (8%) patients developed local recurrence, 30 (31%) developed local and distant recurrences, and 16 (17%) developed distant recurrences alone. The 3-year DSS, post-APR local recurrence-free survival, and disease-free survival were 53.8% (95% CI 43.5-66.5%), 54.5% (95% CI 44.4-66.8%), and 26.8% (95% CI 18.6-38.7%), respectively. In multivariate logistic regression analysis, positive microscopic margin (OR 10.0, 95% CI 2.16-46.12, p = 0.003), positive nodes in the surgical specimen (OR 9.19, 95% CI 1.99-42.52, p = 0.005), and lymphovascular invasion (OR 2.61 95% CI 1.05-6.51, p = 0.04) were associated with recurrence of disease. Gender, indication for APR (recurrent vs. persistent disease), HIV status, extent of surgery, or type of reconstruction did not influence survival outcomes. Twenty patients had targeted tumor-sequencing data available. Nine patients had PIK3CA mutations, seven of whom experienced a recurrence. Conclusions: Salvage APR for anal SCC after failed CRT was associated with poor disease-specific survival and low recurrence-free survival. Anal SCC patients undergoing salvage APR should be counseled that microscopic positive margins, positive lymph nodes, or the presence of lymphovascular invasion in the APR specimen are prognosticators for disease relapse. Our results accentuate the necessity for additional treatment strategies for the ongoing treatment challenge of persistent or recurrent anal SCC after failed CRT.
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Affiliation(s)
- Roni Rosen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Felipe F. Quezada-Diaz
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Georgios Karagkounis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Iris H. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Garrett M. Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Philip B. Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Francisco Sanchez-Vega
- Department of Computational Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Mohammad Adileh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Diana Roth O’Brien
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Vonetta M. Williams
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Marina Shcherba
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Ping Gu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (P.B.R.)
| | - Leonard B. Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (P.G.)
| | - Julio Garcia Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
| | - Emmanouil Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA (F.F.Q.-D.); (J.J.S.)
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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 2024:10.1007/s11845-024-03651-3. [PMID: 38532236 DOI: 10.1007/s11845-024-03651-3] [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: 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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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Dzyubak O, Salman L, Covens A. Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer. Curr Oncol 2024; 31:394-402. [PMID: 38248111 PMCID: PMC10814897 DOI: 10.3390/curroncol31010026] [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: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.
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Affiliation(s)
- Oleksandra Dzyubak
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
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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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7
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [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: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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8
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Liu J, Fu C, Chen Z, Li G. Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis. Int Wound J 2023; 20:3963-3973. [PMID: 37539486 PMCID: PMC10681467 DOI: 10.1111/iwj.14284] [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: 05/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 08/05/2023] Open
Abstract
A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.
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Affiliation(s)
- Jiang Liu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Chao Fu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Zhiliang Chen
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Gang Li
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
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9
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Gendia A, Rehman M, Lin CW, Malik K, Khalil K, Ihedioha U, Kang P, Evans J, Ahmed J. Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience. Int J Colorectal Dis 2023; 38:220. [PMID: 37606697 DOI: 10.1007/s00384-023-04507-5] [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] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh. METHODS We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021. RESULTS 49 patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%. CONCLUSION Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.
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Affiliation(s)
- Ahmed Gendia
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK.
| | - Masood Rehman
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Cindy W Lin
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Kamran Malik
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Khalil Khalil
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Ugo Ihedioha
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Peter Kang
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - John Evans
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Jamil Ahmed
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
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10
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De Crignis L, Dupré A, Meeus P, Peyrat P, Rivoire M. Surgical outcomes in pelvic exenteration for advanced and recurrent malignancy: a high volume single institution experience. Langenbecks Arch Surg 2023; 408:221. [PMID: 37261533 DOI: 10.1007/s00423-023-02960-y] [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: 12/21/2022] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Pelvic exenteration remains the only curative treatment for advanced pelvic malignancies. However, identification of predictive factors for successful surgical outcomes is still a controversial issue at present time. METHODS This retrospective study included data from all adult patients with colorectal or anal advanced pelvic malignancy registered for pelvic exenteration at the Leon Berard Cancer Center (Lyon, France). The primary endpoint was the surgical outcomes and aimed to define the predictive factors for postoperative complications. Secondary endpoints included overall survival and progression free survival in patients having experienced pelvic exenteration (PE). RESULTS Data from 141 patients with locally advanced tumor (N = 81) or recurrent malignancies (N = 60) diagnosed between May 1994 and November 2018 were collected. The median age was 63.3 years (95%CI 20.0-92.0). Malignancies included different locations (rectal: 69.5%, left colon: 17.0% and anal: 13.5%). Posterior pelvectomy was the most frequent surgery (81.6%). The median length of hospital stay was 23.3 days (95%CI 3.0-82.0). The major complication rate at 30 days was 24.8% and 38.1% at 90 days. The median overall survival was 54.5 months (95%CI 41.5-104.1) and the median PFS was 34.5 months (95%CI 19.6-NA). CONCLUSION In selected patients, pelvic exenteration is associated with good surgical and survival outcomes.
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Affiliation(s)
- Lucas De Crignis
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France.
| | - Aurélien Dupré
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
- Univ Lyon, Inserm, U1032 LabTau, 69003, Lyon, France
| | - Pierre Meeus
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Patrice Peyrat
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Michel Rivoire
- Department of Surgical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
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11
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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12
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Gambardella C, Mongardini FM, Karpathiotakis M, Lucido FS, Pizza F, Tolone S, Parisi S, Nesta G, Brusciano L, Gambardella A, Docimo L, Mongardini M. Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study. Cancers (Basel) 2023; 15:2725. [PMID: 37345062 PMCID: PMC10216202 DOI: 10.3390/cancers15102725] [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: 04/15/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure. METHODS From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152). CONCLUSIONS In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.
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Affiliation(s)
- Claudio Gambardella
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Menelaos Karpathiotakis
- Division of General Surgery, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.K.); (M.M.)
| | - Francesco Saverio Lucido
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Francesco Pizza
- Department of Surgery, Hospital ‘A. Rizzoli’, Lacco Ameno, 80076 Naples, Italy;
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Simona Parisi
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Giusiana Nesta
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Luigi Brusciano
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Antonio Gambardella
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
| | - Ludovico Docimo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Massimo Mongardini
- Division of General Surgery, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.K.); (M.M.)
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13
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Thomsen TV, Warming P, Hasanbegovic E, Rindom MB, Stolle LB. 30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-022-02022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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14
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DeLozier OM, Stiles ZE, Shibata D, Deneve JL, Monroe J, Dickson PV, Mathew A, Chandler RG, Behrman SW. Gracilis Flap Reconstruction After Proctocolectomy for Malignancy and Inflammatory Bowel Disease. Am Surg 2023; 89:247-254. [PMID: 33886373 DOI: 10.1177/00031348211011146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Gracilis flap reconstruction (GFR) following abdominoperineal resection (APR) or proctocolectomy (PC) can reduce pelvic wound complications but has not been adequately assessed in the setting of immunosuppression, fistulous disease, and neoadjuvant chemoradiation. METHODS Patients undergoing APR/PC with GFR were retrospectively analyzed with regard to perioperative characteristics, and morbidity was assessed. RESULTS Patients underwent GFR for rectal cancer (n = 28), anal cancer (n = 3), inflammatory bowel disease (n = 13), or benign fistulizing disease (n = 1). 22.2% were chronically immunosuppressed, and 66.7% underwent preoperative chemoradiation. Twenty (44.4%) patients had minor wound complications, all treated nonoperatively. Nine patients had major complications with 4 patients requiring reoperation. The 4 threatened flaps were unilateral, and all were salvaged. Donor site morbidity was minimal. Patients with major complications were older (56 vs. 71 years, P = .030), and less likely to have pelvic drains (P = .018). CONCLUSION In high-risk perineal wounds, GFR offers durable reconstruction with acceptably low morbidity.
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Affiliation(s)
- Olivia M DeLozier
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zachary E Stiles
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin Monroe
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alex Mathew
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert G Chandler
- Department of Plastic Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephen W Behrman
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
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15
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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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Puyana S, Hajebian HH, Kresofsky K, Burko I, Mejia N, Babycos CR. Perineal Surgery: A Novel Use for the Keller Funnel. EPLASTY 2022; 22:QA3. [PMID: 36478956 PMCID: PMC9703911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
What are the effects of radiation therapy on local tissue and structures seen in anterior perineal resection requiring vertical rectus abdominis myocutaneous flap coverage?What are the indications and benefits of the Keller Funnel?What are important factors that affect vertical rectus abdominis myocutaneous flap viability in anterior perineal resection?Why was the Keller Funnel indicated compared with other techniques in the setting of a narrow pelvic inlet?
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Affiliation(s)
- Salomon Puyana
- Department of Plastic and Reconstructive Surgery, Ochsner Clinic Foundation, New Orleans, LA
- Division of Plastic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Hooman H Hajebian
- Department of Plastic and Reconstructive Surgery, Ochsner Clinic Foundation, New Orleans, LA
| | - Kevin Kresofsky
- Department of Plastic and Reconstructive Surgery, Ochsner Clinic Foundation, New Orleans, LA
- Division of Plastic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Igor Burko
- Department of Plastic and Reconstructive Surgery, Ochsner Clinic Foundation, New Orleans, LA
- Division of Plastic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Natalia Mejia
- Department of Plastic and Reconstructive Surgery, Ochsner Clinic Foundation, New Orleans, LA
| | - Christopher R Babycos
- Department of Plastic and Reconstructive Surgery, Ochsner Clinic Foundation, New Orleans, LA
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Fascia Lata Grafting Combined with Gluteal Flaps for Pelvic Floor Reconstruction after Oncologic Resection. Plast Reconstr Surg Glob Open 2022; 10:e4528. [PMID: 36246078 PMCID: PMC9556018 DOI: 10.1097/gox.0000000000004528] [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: 06/07/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
Abstract
Although recent methods of pelvic reconstruction using myocutaneous flaps have reduced postoperative morbidities' including pelvic abscess, the complication rates are still high due to the presence of a large dead cavity and poorly vascularized tissues secondary to preoperative chemoradiation therapy. We aimed to evaluate the usefulness and benefit of fascia lata autografting for pelvic floor reconstruction as a supplemental procedure for gluteal flap closure of perineal wounds. Methods Our retrospective study included 144 consecutive patients who underwent rectal cancer resection with or without pelvic reconstruction, from 2010 to 2020. For reconstruction, fascia lata autografts were harvested from the thigh and affixed to the pelvic floor. The perineal wound was closed using gluteal advancement flaps. Results The study included 33 reconstructed and 111 nonreconstructed patients (average age: 69.5 years). The reconstructed group was more likely to have undergone preoperative chemotherapy (81.8% versus 40.5%, P < 0.001) and radiotherapy (78.8% versus 48.6%, P = 0.002), compared with the nonreconstructed group. Additionally, the reconstructed group underwent fewer abdominoperineal resections (63.6% versus 94.6%, P < 0.001) and more pelvic exenterations (36.4% versus 5.4%). The mean size of fascia lata autografts was 8.3 × 5.9 cm. There were significant differences between the reconstructed and nonreconstructed groups, in the incidences of complications (15.2% versus 33.3%, P = 0.044) and pelvic abscess (3.0% versus 16.2%, P = 0.049). Conclusion Combination of fascia lata autografts and gluteal flaps is considered an effective method of pelvic reconstruction for its low incidence of complications and stable outcomes.
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Meuli JN, Hubner M, Martineau J, Oranges CM, Guillier D, Raffoul W, di Summa PG. Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: A retrospective cohort study. J Surg Oncol 2022; 127:40-47. [PMID: 36112361 PMCID: PMC10087003 DOI: 10.1002/jso.27092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Large and deep perineal defects following abdominal perineal resection (APR) are a challenge for reconstructive surgeons. Even if generally performed for oncological reasons, APR can be indicated as well in extended infection-related debridement for Hidradenitis suppurativa, Fournier's gangrene, or Crohn's disease. We aimed to compare the outcomes of two groups of patients with different indications for APR (infectious vs. oncological) after pedicled anterolateral thigh (ALT) flap coverage RESULTS: Forty-four consecutive pedicled ALT flap used for coverage after APR in 40 patients were analyzed. 26 patients (65%) underwent APR for oncological reasons and 14 patients (35%) for infectious reasons. The overall postoperative complications rate was significantly higher for infectious cases (76.5% vs. 40.7%, p = 0.0304). Major complications occurred in 52.9% of infectious cases versus 11.1% of oncological cases (p = 0.0045). Obesity and infectious etiology were independent risk factors for overall and major complications, respectively. CONCLUSION Patients undergoing APR for acute or chronic infections had significantly more overall and major complications than patients having oncological APR. Modified care might be considered, especially in obese patients, in terms of surgical debridement, antibiotic treatment modalities, and postoperative management.
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Affiliation(s)
- Joachim N. Meuli
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Martin Hubner
- Department of Visceral Surgery Lausanne University Hospital Lausanne Switzerland
| | - Jérôme Martineau
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Carlo M. Oranges
- Department of Plastic, Reconstructive and Aesthetic Surgery Geneva University Hospitals Geneve Switzerland
| | - David Guillier
- Unit of Facial, Plastic, Reconstructive, Aesthetic and Hand Surgery CHU Dijon Dijon France
| | - Wassim Raffoul
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Pietro G. di Summa
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
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Bauzon JS, Tran NV, Hebert BR, Mathis KL. Bowel seromuscular flaps used to repair pelvic defects in patients undergoing reoperative surgery. Tech Coloproctol 2022; 27:373-378. [PMID: 36068396 DOI: 10.1007/s10151-022-02697-8] [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] [Received: 04/26/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pedicled seromuscular bowel flaps may serve as an alternative for pelvic floor reconstruction when conventional omental and muscular flaps are not an option in patients undergoing reoperative abdominopelvic surgery. The aim of this study was to evaluate a unique series of bowel seromuscular flaps used to obliterate intrapelvic defects. METHODS We conducted a retrospective study on all patients in a single tertiary care institutional database who had undergone pelvic reconstruction with a seromuscular bowel flap from January 2006 to December 2018. The primary outcomes measured were the 30-day morbidity and mortality rates. RESULTS Twelve patients (6 men 6 women, median age 56.5 years [range 33-77 years]) underwent reoperative abdominopelvic surgery requiring the use of a native small or large seromuscular bowel flap to obliterate pelvic defects. The indications for surgery included chronic infections, fistulizing Crohn's disease, and cancer. In all cases, no residual omentum was available and rectus abdominis muscle flaps were not feasible due to prior operative scars. Thirty-day morbidity occurred in 5 patients (42%), and included urine leak from ureteral injury, anastomotic leak, acute kidney injury, and superficial surgical site infection. No flaps became ischemic or required removal in the postoperative setting. No mortality was recorded. CONCLUSIONS Bowel seromuscular flaps are a feasible and safe alternative for covering pelvic defects in patients who are undergoing reoperative surgery without the option to use traditional omental and muscular flaps.
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Affiliation(s)
- J S Bauzon
- Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, NV, USA
| | - N V Tran
- Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - B R Hebert
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA
| | - K L Mathis
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, 55905, USA.
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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: 2] [Impact Index Per Article: 1.0] [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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Pérez-García A, García-Granero Á, Thione A, Frasson M, Sánchez-García A, Salmerón-González E, Simón E, Domingo S, García-Granero E. Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection. J Surg Oncol 2022; 126:1383-1388. [PMID: 36003058 DOI: 10.1002/jso.27068] [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: 02/06/2022] [Revised: 07/14/2022] [Accepted: 08/07/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection. METHODS A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space. RESULTS Forty-four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence. CONCLUSIONS The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.
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Affiliation(s)
- Alberto Pérez-García
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | | | - Alessandro Thione
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | - Matteo Frasson
- Department of General Surgery, La Fe University Hospital, Valencia, Spain
| | | | | | - Eduardo Simón
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology, La Fe University Hospital, Valencia, Spain
| | - E García-Granero
- Department of General Surgery, La Fe University Hospital, Valencia, Spain
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Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction. Plast Reconstr Surg 2022; 150:190-195. [PMID: 35583937 DOI: 10.1097/prs.0000000000009233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY The rectus abdominis flap has long been a workhorse in perineal reconstruction. Although traditionally approached though an external incision, the morbid nature of the incision and subsequent violation of the anterior rectus sheath has encouraged innovation of minimally invasive approaches for harvest. In this study, we present our experience, evolution, and comparative outcomes of robotic rectus abdominis muscle harvest. A retrospective review of perineal reconstruction was performed for a 6-year period (2014 to 2019). Robotic rectus abdominis muscle flaps were compared to nonrobotic techniques performed during this time. Descriptive statistics and complication profiles were computed. The details of our surgical technique are also described. Thirty-six patients underwent perineal reconstruction. Sixteen were performed using the robotic rectus abdominis muscle and 20 with traditional repairs (12 vertical rectus abdominis myocutaneous flaps and eight gracilis flaps). Demographic profiles were similar between cohorts, including age, body mass index, smoking, diabetes, neoadjuvant radiation therapy, and need for vaginal wall repair. Six robotic patients underwent abdominal wall reinforcement with biological mesh. Length of stay, surgical times, and incidence of major complications were similar between cohorts with a trend toward increased minor complications in traditional reconstructions (55 percent versus 31 percent; p = 0.15). Robotic rectus abdominis muscle harvest is a powerful tool that continues to evolve the potential to mitigate common morbidities and complications of traditional repair and further enhance cosmetic outcomes. This study suggests that greater flexibility for reconstruction can be afforded with harvest of the posterior rectus sheath and complications avoided with prophylactic mesh reinforcement. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Jackisch J, Jackisch T, Roessler J, Sims A, Nitzsche H, Mann P, Mees ST, Stelzner S. Tailored concept for the plastic closure of pelvic defects resulting from extralevator abdominoperineal excision (ELAPE) or pelvic exenteration. Int J Colorectal Dis 2022; 37:1669-1679. [PMID: 35750763 DOI: 10.1007/s00384-022-04196-6] [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] [Accepted: 06/01/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE No standard exists for reconstruction after extralevator abdominoperineal excision (ELAPE) and pelvic exenteration. We propose a tailored concept with the use of bilateral gluteal V-Y advancement flaps in non-extended ELAPE and with vertical myocutaneous rectus abdominis muscle (VRAM) flaps in extended procedures. This retrospective study analyzes the feasibility of this concept. PATIENTS AND METHODS We retrieved all consecutive patients after ELAPE or pelvic exenteration for rectal, anal, or vulva cancer with flap repair from a prospective database. Perineal wound complications were defined as the primary endpoint. Outcomes for the two different flap reconstructions were analyzed. RESULTS From 2005 to 2021, we identified 107 patients who met the study criteria. Four patients underwent exenteration with VRAM flap repair after previous V-Y flap fashioning. Therefore, we report on 75 V-Y and 36 VRAM flaps. The V-Y group contained more rectal carcinomas, and the VRAM group exhibited more patients with recurrent cancer, more multivisceral resections, and longer operation times. Perineal wound complications occurred in 21.3% in the V-Y group and in 36.1% in the VRAM group (p = 0.097). Adjusted odds ratio for perineal wound complication was not significantly different for the two flap types. CONCLUSION Concerning perineal wound complications, our concept yields favorable results for V-Y flap closure indicating that this less invasive approach is sufficient for non-extended ELAPE. Advantages are a shorter operation time, less donor site morbidity, and the option of a second repair. VRAM flaps were reserved for larger wounds after pelvic exenteration or vaginal repair.
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Affiliation(s)
- Julia Jackisch
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Thomas Jackisch
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Joerg Roessler
- Clinic for Plastic and Aesthetic Surgery, Oberer Kreuzweg 8, Dresden, D-01097, Germany
| | - Anja Sims
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Holger Nitzsche
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Pia Mann
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Sören Torge Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany. .,Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, Leipzig, D-04103, Germany.
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Dayani F, Sheckter CC, Rochlin DH, Nazerali RS. System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection. Plast Reconstr Surg 2022; 149:225-232. [PMID: 34813526 DOI: 10.1097/prs.0000000000008661] [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 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.
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Affiliation(s)
- Fara Dayani
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
| | - Clifford C Sheckter
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
| | - Danielle H Rochlin
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
| | - Rahim S Nazerali
- From the University of California, San Francisco, School of Medicine; and Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine
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Johnson YL, West MA, Gould LE, Drami I, Behrenbruch C, Burns EM, Mirnezami AH, Jenkins JT. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022; 24:16-26. [PMID: 34653292 DOI: 10.1111/codi.15956] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/12/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
AIM Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. METHOD The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. RESULTS Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). CONCLUSION The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.
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Affiliation(s)
- Yanika L Johnson
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Malcolm A West
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Laura E Gould
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | | | | | - Alexander H Mirnezami
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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Discussion: System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection. Plast Reconstr Surg 2022; 149:233-234. [PMID: 34936626 DOI: 10.1097/prs.0000000000008664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alemrajabi M, Khavanin Zadeh M, Hemmati N, Banivaheb B, Alemrajabi F, Jahanian S, Bahadoram M, Barahman M. Inferior Part of Rectus Abdominis Muscle Flap Outcomes after Abdominoperineal Resection: A Case Series Pilot Study. World J Plast Surg 2021; 10:104-110. [PMID: 34912674 PMCID: PMC8662682 DOI: 10.29252/wjps.10.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The standard surgical treatment for low rectal cancer is abdominoperineal resection (APR). Comparing to primary closure, immediate flap reconstruction has shown to have good outcomes. We aimed to assess the inferior rectus abdominis muscle flap complications after APR surgery, a new method of reconstruction. METHODS This study was conducted from 2014 to 2016 in a single center in Firoozgar Hospital, Tehran, Iran. Eighteen patients who underwent pelvic floor closure with inferior part of abdominis rectus musculofascial flap were included enrolled. The sampling method used in this study was census. All patients had distal rectoanal malignancies. A checklist including age, gender, tumor location, complications after surgery, tumor type, length of hospital stay, length of operation, neoadjuvant chemotherapy and neoadjuvant radiotherapy history was filled for all patients. RESULTS Among 18 participants, 27.8% were female. The mean age of participants was 58.28 ± 17.86 yr (minimum of 19 and the maximum of 89 yr). The pathology of the tumor in all but one of the cases was adenocarcinoma (94.4%). The overall complication rate after surgery was 27.8%. In total, 80% received neoadjuvant chemoradiotherapy. In 12 months follow-up 2 patients needed reoperation. CONCLUSION Inferior part of rectus abdominis muscle flap was a reliable and comparable means of reconstruction after APR surgery with low rate of complications and mortality.
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Affiliation(s)
- Mahdi Alemrajabi
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Morteza Khavanin Zadeh
- Hasheminejad Kidney Center (HKC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Nima Hemmati
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Behrouz Banivaheb
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Fatemeh Alemrajabi
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Sepideh Jahanian
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mohammad Bahadoram
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maedeh Barahman
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
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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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Bernuth S, Jakubietz M, Isbert C, Reibetanz J, Meffert R, Jakubietz R, Schmidt K. Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer. Technol Health Care 2021; 30:815-825. [PMID: 34744033 DOI: 10.3233/thc-213021] [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: 11/15/2022]
Abstract
BACKGROUND Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. OBJECTIVE Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. METHODS 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. RESULTS Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. CONCLUSION The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.
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Affiliation(s)
- Silvia Bernuth
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Michael Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Christoph Isbert
- Department of General, Visceral and Coloproctological Surgery, Amalie Sieveking Hospital Hamburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Germany
| | - Rainer Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Rafael Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Karsten Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
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Zeiderman MR, Nuño M, Sahar DE, Farkas LM. Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample. J Plast Reconstr Aesthet Surg 2021; 74:2085-2094. [PMID: 33455867 DOI: 10.1016/j.bjps.2020.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 12/07/2020] [Accepted: 12/19/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Flap reconstruction of radiated pelvic oncologic defects decreases perineal wound-healing complications. How widely and how often reconstructions are performed, and how technical mastery and improved perioperative care has affected outcomes, is unknown. Our objective is to 1) provide a comprehensive evaluation of national trends in flap reconstruction of pelvic oncologic defects and 2) compare complications and length of stay (LOS) in patients with/without reconstruction. METHODS The National Inpatient Sample (NIS) database was queried (1998-2014) for patients diagnosed with cancer, primarily of the rectum and anus, who underwent abdominoperineal resection (APR) or pelvic exenteration (PE). Differences in complications and LOS were compared between patients with flap reconstruction versus primary closure. Regional and hospital outcomes were also analyzed. RESULTS The cohort included 117,923 adult patients; 3,673 (3.1%) underwent flap reconstruction. Flap reconstruction rates increased from 0.8% in 1998 to 9.8% in 2014. Extirpative procedures decreased 37.4% from 1998 to 2014. Flap reconstruction decreased risk of wound breakdown (OR 0.87; p = 0.0029) and need for secondary closure of dehiscence (OR 0.82; p = 0.0023) between periods 1998-2009 and 2010-2014. Median LOS was higher for flap patients (median [IQR] of 9.8 [7.2,14.8] vs. 7.9 [6.1-11.0; p < 0.0001) and decreased over time. CONCLUSIONS The use of flap reconstruction for pelvic oncologic defects increased from 1998 to 2014, with a reduction in LOS. Following flap reconstruction, overall complications are higher, but wound breakdown and dehiscence requiring reclosure are decreasing, suggesting technique maturation. We anticipate flap reconstruction rates will increase with further improvement in patient outcomes.
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Affiliation(s)
- Matthew R Zeiderman
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA; Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA.
| | - Miriam Nuño
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA; Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA; Department of Public Health Sciences, Division of Biostatistics, University of California, Davis USA
| | - David E Sahar
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA
| | - Linda M Farkas
- Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA; Department of Surgery, Division of Colon and Rectal Surgery, University of Texas Southwestern Medical Center USA.
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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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Stein MJ, Karir A, Hanson MN, Cavale N, Almoudaris AM, Voineskos S. Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons. J Reconstr Microsurg 2021; 38:89-95. [PMID: 34187060 DOI: 10.1055/s-0041-1729750] [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 Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs). METHODS Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management. RESULTS Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%). CONCLUSION A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.
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Affiliation(s)
- Michael J Stein
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Canada
| | - Aneesh Karir
- Division of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, Canada
| | - Melissa N Hanson
- Division of General Surgery, McGill University, Montreal, Canada
| | - Naveen Cavale
- Division of Plastic and Reconstructive Surgery, Kings College, London, United Kingdom
| | - Alex M Almoudaris
- Division of General Surgery, University College Hospital, London, United Kingdom
| | - Sophocles Voineskos
- Division of Plastic and Reconstructive Surgery, McMaster University, Hamilton, Ontario, Canada
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Moraru DC, Scripcariu DV, Ferariu D, Scripcariu V, Filip B. Perineal eventration after abdominoperineal resection for rectal cancer: anatomical, surgical and clinico-pathological landmarks. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY 2021; 61:1111-1119. [PMID: 34171060 PMCID: PMC8343492 DOI: 10.47162/rjme.61.4.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of evolution, out of 620 patients with rectal cancer treated by curative surgery, 176 patients with lower ampullary rectal cancer treated by abdominoperineal resection (APR) with the closure of the defect by direct suture of the perineal floor were selected. Ten (5.6%) of them were diagnosed with PE. This paper shows the results of a retrospective study, which compares the clinico-pathological and therapeutic aspects of a subgroup of 166 patients (subgroup I) with APR without PE and a subgroup of 10 patients (subgroup II) with PE. Starting from the question of whether aspects can influence the evolution of PE, we aimed to investigate the similarities and differences between these two groups, from the histological, clinical and therapeutic points of view. Regarding the tumor, node, metastasis (TNM) staging, we encountered the following aspects: for the subgroup II with PE, pT3 predominated, stages N0 and N1 were equal (50%) and the absence of metastases (M0) was found in all cases; in subgroup I, pT3 and N0 also predominated, followed by N1 and N2, and for stage M, M0 is predominant, followed by M1. For the clinical profile of the PE group, the symptoms were characteristic, with the presence of the usual triggering factors [hysterectomy, radiochemotherapy and wide resection surgery – extralevatorial APR]. The therapeutic approach revealed various aspects, including plastic surgery procedures (direct closure, meshes, flaps) used in pelvic reconstruction. The accurate surgical technique applied in order to achieve oncological safety allowed for a longer survival, which favored the appearance of PE in addition to the other favoring factors. Our results underlined the clinico-pathological profile of the two subgroups, without being able to establish a correlation with the appearance and evolution of PE. However, the clinico-pathological risk factors for this condition are not yet fully defined. Therefore, reports based on the experience in the diagnosis and treatment of PE should bring valuable data, aiming to create the knowledge framework for prevention.
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Affiliation(s)
- Dan Cristian Moraru
- Department of Surgery I, Grigore T. Popa University of Medicine and Pharmacy, 1st Surgical Oncology Unit, Regional Institute of Oncology, Iaşi, Romania;
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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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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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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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Dee EC, Byrne JD, Wo JY. Evolution of the Role of Radiotherapy for Anal Cancer. Cancers (Basel) 2021; 13:1208. [PMID: 33801992 PMCID: PMC8001637 DOI: 10.3390/cancers13061208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 12/11/2022] Open
Abstract
Prior to the 1980s, the primary management of localized anal cancer was surgical resection. Dr. Norman Nigro and colleagues introduced neoadjuvant chemoradiotherapy prior to abdominoperineal resection. Chemoradiotherapy 5-fluorouracil and mitomycin C afforded patients complete pathologic response and obviated the need for upfront surgery. More recent studies have attempted to alter or exclude chemotherapy used in the Nigro regimen to mitigate toxicity, often with worse outcomes. Reductions in acute adverse effects have been associated with marked advancements in radiotherapy delivery using intensity-modulated radiation therapy (IMRT) and image-guidance radiation delivery, resulting in increased tolerance to greater radiation doses. Ongoing trials are attempting to improve IMRT-based treatment of locally advanced disease with efforts to increase personalized treatment. Studies are also examining the role of newer treatment modalities such as proton therapy in treating anal cancer. Here we review the evolution of radiotherapy for anal cancer and describe recent advances. We also elaborate on radiotherapy's role in locally persistent or recurrent anal cancer.
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Affiliation(s)
| | - James D. Byrne
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA 02115, USA;
| | - Jennifer Y. Wo
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA;
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114, USA
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Zaheer Ahmad N, Abbas MH, Al-Naimi NMAB, Parvaiz A. Meta-analysis of biological mesh reconstruction versus primary perineal closure after abdominoperineal excision of rectal cancer. Int J Colorectal Dis 2021; 36:477-492. [PMID: 33392663 DOI: 10.1007/s00384-020-03827-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Extralevator abdominoperineal excision (ELAPE) of rectal cancer has been proposed to achieve better oncological outcomes. The resultant wide perineal wound, however, presents a challenge for primary closure and subsequent wound healing. This meta-analysis compared the outcomes of primary perineal closure with those of biological mesh reconstruction. METHODS The Medline and Embase search was performed for the publications comparing primary perineal closure to biological mesh reconstruction. Early perineal wound complications (seroma, infection, dehiscence) and late perineal wound complications (perineal hernia, chronic pain, and chronic sinus) were analyzed as primary endpoints. Intraoperative blood loss, operation time, and hospital stay were compared as secondary endpoints. RESULTS There was no significant difference in the overall early wound complications after primary closure or biological mesh reconstruction (odds ratio (OR) of 0.575 with 95% confidence interval (CI) of 0.241 to 1.373 and a P value of 0.213). The incidence of perineal hernia after 1 year was significantly high after primary closure of the perineal wounds (OR of 0.400 with 95% CI of 0.240 to 0.665 and a P value of 0.001). No significant differences were observed among other early and late perineal wound complications. The operation time and hospital stay were shorter after primary perineal closure (p 0.001). CONCLUSION A lower incidence of perineal hernia and comparable early perineal wound complications after biological mesh reconstruction show a relative superiority over primary closure. More randomized studies are required before a routine biological mesh reconstruction can be recommended for closure of perineal wounds after ELAPE.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co., Limerick, V94 F858, Republic of Ireland.
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | | | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, UK.,Colorectal Department, Poole NHS Trust Poole UK, Poole, UK
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Buscail E, Canivet C, Shourick J, Chantalat E, Carrere N, Duffas JP, Philis A, Berard E, Buscail L, Ghouti L, Chaput B. Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040721. [PMID: 33578769 PMCID: PMC7916499 DOI: 10.3390/cancers13040721] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C. Abstract Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
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Affiliation(s)
- Etienne Buscail
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
- INSERM, U1220, Digestive Health Research Institute (IRSD), University of Toulouse, 31100 Toulouse, France
| | - Cindy Canivet
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
- Department of Gastroenterology and Pancreatology, Toulouse University Hospital, 31100 Toulouse, France
| | - Jason Shourick
- Department of Epidemiology and Public Health, UMR 1027 INSERM, Toulouse University Hospital, University of Toulouse, 31100 Toulouse, France; (J.S.); (E.B.)
| | - Elodie Chantalat
- Department of Surgery, Oncopole, INSERM-UPS UMR U1048, Institute of Metabolic and Cardiovascular Diseases, University of Toulouse, 31100 Toulouse, France;
| | - Nicolas Carrere
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Jean-Pierre Duffas
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Antoine Philis
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Emilie Berard
- Department of Epidemiology and Public Health, UMR 1027 INSERM, Toulouse University Hospital, University of Toulouse, 31100 Toulouse, France; (J.S.); (E.B.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Toulouse University Hospital, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-61-32-30-55; Fax: +33-5-61-32-22-29
| | - Laurent Ghouti
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Toulouse University Hospital, 31100 Toulouse, France;
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Galliamov EA, Agapov MA, Markaryan DR, Kakotkin VV, Kazachenko EA, Kubyshkin VA. RECURRENT PERINEAL HERNIA — LAPAROSCOPIC SURGICAL TREATMENT: CLINICAL CASE. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-3-59-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Recurrent postoperative perineal hernia is a rare complication of such operation as posterior pelvic evisceration. This condition can reduce the quality of life in the postoperative period and requires surgical restoration of the impaired pelvic anatomy.Clinical case: A 54-year old female patient applied to the MSU University clinic in July 2020 with the protrusion in the perineal area. She was diagnosed with recurrent perineal postoperative hernia. She was diagnosed with rectal cancer T4N1M0 and uterine dysplasia in 2017, 6 courses of neoadjuvant polychemoradiation therapy were performed; she underwent extralevator abdominal-perineal resection with uterine extirpation and the permanent colostomy formation in 2018. A perineal postoperative hernia was diagnosed in March 2020, perineal transabdominal plastic surgery was performed with a mesh implant. A recurrent perineal hernia was diagnosed in April 2020, the patient underwent laparoscopic alloplasty with a composite mesh implant. On the 9th postoperative day, she was discharged in a satisfactory condition without any complaints.Conclusion: Postoperative perineal hernia is a fairly rare complication in surgical practice. The recurrent rate is quite high. The insufficient number of patients, the short follow-up period and the wide range of surgical treatment methods do not allow evaluating the results adequately. It is necessary to conduct large randomized clinical trials to assess the efficacy of surgical interventions and to determine the indications for certain procedures.
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Affiliation(s)
- E. A. Galliamov
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU); Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - D. R. Markaryan
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - V. V. Kakotkin
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - E. A. Kazachenko
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - V. A. Kubyshkin
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
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LaBove GA, Evans GR, Biggerstaff B, Richland BK, Lee SA, Banyard DA, Khoshab N. Ten-Year experience with vertical rectus abdominis myocutaneous flap for reconstruction of abdominoperineal resection defects. JPRAS Open 2020; 27:90-98. [PMID: 33376767 PMCID: PMC7758273 DOI: 10.1016/j.jpra.2020.11.010] [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: 08/23/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose We evaluate outcomes of our single center using vertical rectus abdominis myocutaneous (VRAM) flaps for reconstruction after abdominoperineal resection (APR). Our goal was to analyze factors that may affect perineal wound healing, a problematic complication with APR reconstructions due to location and high frequency of neoadjuvant chemoradiation. Methods This single-center, retrospective study analyzed all VRAM flap perineal reconstruction patients after APR defect over a 10-year period (from July 2008 to June 2018). Outcome measures focused on factors that may affect perineal wound healing complication rates: cancer stage (I/II vs III/IV), neoadjuvant chemoradiation, surgeon's years in practice (<5 years vs >5 years), and pelvic closed suction drain use. Results Twenty-eight patients met inclusion criteria. The overall major perineal wound complication rate was 14.3% (4 patients). Lack of perioperative closed suction pelvic drain use was associated with a significantly higher rate of major perineal wound complications (28.6% vs 0% and p = 0.031). All four major wound complications occurred in patients who did not have a pelvic drain. The major perineal wound complication rate for patients who underwent neoadjuvant chemoradiation was 22% vs 0% with no neoadjuvant chemoradiation (p = 0.107). Conclusion While our cohort represents a relatively small single-center study, our 14.3% rate of major perineal wound complications is consistent with previous studies in the literature. Our findings show that perioperative pelvic closed suction drain use is associated with a lower rate of perineal wound complications. While neoadjuvant chemoradiation trended toward a higher incidence of perineal wound complications, it did not reach statistical significance.
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Affiliation(s)
- Gabrielle A LaBove
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Gregory Rd Evans
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Brian Biggerstaff
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Brandon K Richland
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Seung Ah Lee
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Derek A Banyard
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Nima Khoshab
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
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Kaneko T, Funahashi K, Ushigome M, Kagami S, Goto M, Koda T, Kurihara A. Incisional negative pressure wound therapy to reduce perineal wound infection after abdominoperineal resection. Int Wound J 2020; 18:103-111. [PMID: 33236842 PMCID: PMC7948915 DOI: 10.1111/iwj.13499] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 01/03/2023] Open
Abstract
We explored the effects of incisional negative pressure wound therapy in perineal wound infections after abdominoperineal resection. We retrospectively evaluated 146 patients who underwent abdominal perineal resection from December 2004 to December 2019 and compared conventional gauze dressing (controls) with incisional negative pressure wound therapy. We compared patients' characteristics, surgical factors, and perineal infection rates between groups, and patients' characteristics, surgical factors, and negative pressure therapy use between perineal infection vs non-infection groups, as well as the risk factors for perineal infections. In the negative pressure therapy group, compared with controls, the number of men, smoking prevalence, blood transfusion, drainage via the perineal wound, and intraoperative blood loss were significantly lower (p < 0.05, p < 0.05, p < 0.05, p < 0.001, p < 0.01, respectively), and operation time was significantly longer (p < 0.05). Infections were significantly less common in the negative pressure group (p < 0.05). In the univariate analysis, the infection-positive group had significantly higher laparoscopic surgery (p < 0.01) and negative pressure wound therapy-free rates (p < 0.01), and significantly more intraoperative blood loss (p < 0.05). Multivariate analysis using these three factors and preoperative radiotherapy showed that incisional negative pressure wound therapy-free status was a risk factor for infection. Incisional negative pressure wound therapy was beneficial in managing perineal wound infections after abdominoperineal resection.
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Affiliation(s)
- Tomoaki Kaneko
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Kimihiko Funahashi
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Mitstunori Ushigome
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Satoru Kagami
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Mayu Goto
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Takamaru Koda
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Akiharu Kurihara
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
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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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An Aggressive Tumoral Metastasis to Groin Arising from Perianal Squamous Cell Carcinoma: Management of a Unique Case. Indian J Surg Oncol 2020; 11:90-92. [PMID: 33088138 DOI: 10.1007/s13193-020-01063-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/27/2020] [Indexed: 10/24/2022] Open
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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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Garcia-Henriquez N, Galante DJ, Monson JRT. Selection and Outcomes in Abdominoperineal Resection. Front Oncol 2020; 10:1339. [PMID: 33014775 PMCID: PMC7461900 DOI: 10.3389/fonc.2020.01339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/26/2020] [Indexed: 01/14/2023] Open
Abstract
Since the initial descriptions of the abdominoperineal resection by Sir William Ernest Miles which was then followed by the perfection of the total mesorectal excision by Professor Bill Heald, the surgical management of rectal cancer has made tremendous strides. However, even with the advent and sophistication of neoadjuvant therapy, there remains a formidable amount of patients requiring an abdominoperineal resection. The purpose of this review is to delineate the indication and selection process by which patients are determined to require an abdominoperineal resection, as well as the oncologic and overall outcomes associated with the operation.
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Affiliation(s)
| | - Daniel J Galante
- Advent Health Medical Group, Center for Colon and Rectal Surgery, Orlando, FL, United States
| | - John R T Monson
- Advent Health Medical Group, Center for Colon and Rectal Surgery, Orlando, FL, United States
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