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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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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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Ouyang Y, Zhu Y, Chen H, Li G, Hu X, Luo H, Li Z, Han S. Case Report: Long-term survival of a patient with advanced rectal cancer and multiple pelvic recurrences after seven surgeries. Front Oncol 2023; 13:1169616. [PMID: 37256170 PMCID: PMC10225707 DOI: 10.3389/fonc.2023.1169616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/04/2023] [Indexed: 06/01/2023] Open
Abstract
Background Rectal cancer has a high risk of recurrence and metastasis, with median survival ranging from 24 months to 36 months. K-RAS mutation is a predictor of poor prognosis in rectal cancer. Advanced rectal cancer can be stopped in its tracks by pelvic exenteration. Case summary A 51-year-old woman was diagnosed with advanced rectal cancer (pT4bN2aM1b, stage IV) with the KRAS G12D mutation due to a change in bowel habits. The patient had experienced repeated recurrences of rectal cancer after initial radical resection, and the tumor had invaded the ovaries, sacrum, bladder, vagina and anus. Since the onset of the disease, the patient had undergone a total of seven surgeries and long-term FOLFIRI- or XELOX-based chemotherapy regimens, with the targeted agents bevacizumab and regorafenib. Fortunately, the patient was able to achieve intraoperative R0 resection in almost all surgical procedures and achieve tumor-free survival after pelvic exenteration. The patient has been alive for 86 months since her diagnosis. Conclusions Patients with advanced rectal cancer can achieve long-term survival through active multidisciplinary management and R0 surgery.
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Affiliation(s)
- Ye Ouyang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yilin Zhu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Haoyi Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Guoquan Li
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Xiongwei Hu
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Hongyu Luo
- Department of General Surgery, Guangdong Province Huizhou Sixth Hospital, Huizhou, China
| | - Zhou Li
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shuai Han
- Department of Gastrointestinal Surgery, General Surgery Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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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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Oversized lotus petal flap for reconstruction of extensive perineal defects following abdomino perineal resection. ANN CHIR PLAST ESTH 2022; 67:224-231. [DOI: 10.1016/j.anplas.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022]
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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: 22] [Impact Index Per Article: 11.0] [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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Abstract
SUMMARY Vascularized tissue for obliteration of large pelvic dead spaces created by extirpative surgery has been shown to reduce complication rates. As more extensive resections are performed robotically, plastic surgeons have been challenged to reconstruct the resulting defects using a minimally invasive approach. The goal of this study was to report the authors' experience with robotic harvest of the rectus abdominis muscle for reconstruction of pelvic defects. The authors conducted a retrospective case series of patients who underwent robotic flap harvest following robotic extirpative surgery at their institution. Patient demographics, surgical characteristics, and postoperative outcomes were collected. These were compared to a retrospective cohort of patients who underwent open rectus abdominis muscle harvest. The authors identified seven male patients who underwent robotic flap harvest for pelvic reconstruction between 2013 and 2019. Their mean age was 66 ± 6 years and mean body mass index was 31 ± 5 kg/m2. Six patients (86 percent) had a history of radiation therapy and five patients (71 percent) received hormone therapy or chemotherapy. Surgical-site complications occurred in two patients. One patient developed ventral hernia. The donor-site complication rate was 19 percent (n = 18) in patients who underwent open rectus abdominis muscle harvest (n = 95). This study demonstrates the safety, efficacy, and reproducibility of robotic harvest of the rectus abdominis muscle in complex, multidisciplinary, minimally invasive pelvic surgery. The technique avoids violation of the anterior rectus sheath and wound complications related to open flap harvest, and early experience suggests reduced donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Rogers AC, Jenkins JT, Rasheed S, Malietzis G, Burns EM, Kontovounisios C, Tekkis PP. Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer. J Clin Med 2021; 10:jcm10214921. [PMID: 34768442 PMCID: PMC8584798 DOI: 10.3390/jcm10214921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.
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Affiliation(s)
- Ailín C. Rogers
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - John T. Jenkins
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Shahnawaz Rasheed
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
| | - George Malietzis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
| | - Elaine M. Burns
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Christos Kontovounisios
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
- Correspondence:
| | - Paris P. Tekkis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
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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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11
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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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12
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Gao Z, Gu J. Surgical treatment of locally recurrent rectal cancer: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1026. [PMID: 34277826 PMCID: PMC8267292 DOI: 10.21037/atm-21-2298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
Objective To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC). Background LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life. Methods We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020. Conclusions LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.
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Affiliation(s)
- Zhaoya Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China.,Department of Gastrointestinal Surgery III, Peking University Cancer Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
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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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14
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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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Comparison of Effective Cost and Complications after Abdominoperineal Resection: Primary Closure versus Flap Reconstruction. Plast Reconstr Surg 2020; 144:866e-875e. [PMID: 31688766 DOI: 10.1097/prs.0000000000006158] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Flap reconstruction is recommended for select patients undergoing abdominoperineal resection to mitigate complications. However, the clinical effectiveness and financial implications of flap reconstruction remain unknown. The authors aim to compare the costs and complications for patients undergoing abdominoperineal resection with and without flap reconstruction. METHODS The Truven MarketScan Databases (2009 to 2016) were used to perform retrospective population-based analysis of colorectal carcinoma patients who underwent abdominoperineal resection with and without flap reconstruction. Univariate and multivariable logistic regressions were used to study effective cost (cumulative cost/number of healthy days) and complications. RESULTS Of 2557 total abdominoperineal resection patients, 194 patients underwent flap reconstruction. Patients undergoing flap reconstruction had a higher Elixhauser Comorbidity Index (p = 0.004) and were more likely to have local invasion (p < 0.001). At 6 months postoperatively, there were no differences in complications between the two groups (p = 0.116). Flap reconstruction was protective against intraabdominal infections (OR, 0.4; 95 percent CI, 0.2 to 0.9; p = 0.033) but conferred an increased risk of wound complications (OR, 1.5; 95 percent CI, 1.0 to 2.3; p = 0.039). Total median cost of care was similar (abdominoperineal resection alone, $40,050; abdominoperineal resection with flap, $41,380; p = 0.456). Effective cost was greater for abdominoperineal resection alone ($259/healthy day) than abdominoperineal resection with flap ($186/healthy day) but was not statistically significant (p = 0.17). CONCLUSIONS Patients with flap reconstruction displayed a higher comorbidity score and more extensive disease, but these unfavorable factors did not result in a higher complication rate, total cost, or effective cost. Therefore, flap reconstruction for complex perineal defects confers a benefit in select patients and is a judicious use of health care resources. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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16
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Blok RD, Hagemans JAW, Burger JWA, Rothbarth J, van der Bilt JDW, Lapid O, Hompes R, Tanis PJ. Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer. Tech Coloproctol 2019; 23:751-759. [PMID: 31432332 PMCID: PMC6736901 DOI: 10.1007/s10151-019-02055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 07/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR. METHODS Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures. RESULTS Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35-44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8-12 days). CONCLUSIONS The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.
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Affiliation(s)
- R D Blok
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Meibergdreef 9, Post Box 22660, 1100 DD, Amsterdam, The Netherlands
- LEXOR, Centre for Experimental and Molecular Medicine, Oncode Institute, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J A W Hagemans
- Department of Surgical Oncology, Erasmus Medical Centre, Cancer Institute, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - J W A Burger
- Department of Surgical Oncology, Erasmus Medical Centre, Cancer Institute, Doctor Molewaterplein 40, Rotterdam, The Netherlands
- Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, Eindhoven, The Netherlands
| | - J Rothbarth
- Department of Surgical Oncology, Erasmus Medical Centre, Cancer Institute, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - J D W van der Bilt
- Department of Surgery, Flevo Hospital, Hospitaalweg 1, Almere, The Netherlands
| | - O Lapid
- Department of Plastic and Reconstructive Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Meibergdreef 9, Post Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Meibergdreef 9, Post Box 22660, 1100 DD, Amsterdam, The Netherlands.
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17
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Humphries EL, Kroon HM, Dudi-Venkata NN, Thomas ML, Moore JW, Sammour T. Short- and long-term outcomes of selective pelvic exenteration surgery in a low-volume specialized tertiary setting. ANZ J Surg 2019; 89:E226-E230. [PMID: 31067602 DOI: 10.1111/ans.15212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Most published data on pelvic exenteration comes from high-volume quaternary units, with limited data available from outside of this setting. This study reports outcomes of selective pelvic exenteration performed in a low-volume tertiary unit with multidisciplinary support. METHODS A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. Descriptive statistics and Kaplan-Meier analysis of 5-year disease-free and overall survival for patients treated with curative intent were performed. RESULTS A total of 54 patients who underwent pelvic exenteration were included. Most patients presented with primary rectal adenocarcinoma, and posterior and total pelvic exenterations were the most common operations performed (>90%). Median total operating time was 323 min, median hospital stay was 15 days, and the readmission rate was 14.8%. The overall complication rate (per patient) was 70.4%, and the re-intervention rate was 20.4%. Thirteen percent of patients required intensive care unit-admission, and there was one postoperative death (1.9%). R0 resection margins were achieved in 81.5% of patients, with R1 and R2 margins in 13.0 and 5.6% of patients, respectively. Estimated 5-year disease-free survival was 38.8%, and 5-year overall survival was 65.7%. CONCLUSION Short- and long-term outcomes of selective pelvic exenteration surgery are acceptable in a low-volume specialized tertiary setting with suitable multidisciplinary expertise. If the required expertise is not readily available, then outside referral is recommended.
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Affiliation(s)
- Emily L Humphries
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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18
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The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects. Int J Colorectal Dis 2019; 34:501-511. [PMID: 30610436 DOI: 10.1007/s00384-018-03222-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 02/04/2023]
Abstract
AIM Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.
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Houdek MT, Rose PS, Hevesi M, Schwab JH, Griffin AM, Healey JH, Petersen IA, DeLaney TF, Chung PW, Yaszemski MJ, Wunder JS, Hornicek FJ, Boland PJ, Sim FH, Ferguson PC. Low dose radiotherapy is associated with local complications but not disease control in sacral chordoma. J Surg Oncol 2019; 119:856-863. [PMID: 30734292 DOI: 10.1002/jso.25399] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND We reviewed the disease control and complications of the treatment of sacrococcygeal chordoma from four tertiary cancer centers with emphasis on the effects of radiotherapy in surgically treated patients. METHODS A total of 193 patients with primary sacrococcygeal chordoma from 1990 to 2015 were reviewed. There were 124 males, with a mean age of 59 ± 15 years and a mean follow-up of 7 ± 4 years. Eighty-nine patients received radiotherapy with a mean total dose of 61.8 ± 10.9 Gy. RESULTS The 10-year disease-free and disease-specific survival was 58% and 72%, respectively. Radiation was not associated with local recurrence (hazard ratio [HR], 1.13; 95% confidence interval [CI], 0.59-2.17; P = 0.71), metastases (HR, 0.93; 95% CI, 0.45-1.91; P = 0.85) or disease-specific survival (HR, 0.96; 95% CI, 0.46-2.00; P = 0.91). Higher doses (≥70 Gy; HR, 0.52; 95% CI, 0.20-1.32; P = 0.17) may be associated with reduced local recurrence. Radiotherapy was associated with wound complications (HR, 2.76; 95% CI, 1.64-4.82;, P < 0.001) and sacral stress fractures (HR, 4.73; 95% CI, 1.88-14.38; P < 0.001). CONCLUSIONS In this multicenter review, radiotherapy was not associated with tumor outcome but associated with complications. The routine use of radiotherapy with en-bloc resection of sacrococcygeal chordomas should be reconsidered in favor of a selective, individualized approach with a radiation dose of ≥70 Gy.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony M Griffin
- Division of Orthopaedic Surgery, Department of Surgery, University Musculoskeletal Oncology Unit Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - John H Healey
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center and Weill College of Medicine, Cornell University, New York, New York
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter W Chung
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada
| | | | - Jay S Wunder
- Division of Orthopaedic Surgery, Department of Surgery, University Musculoskeletal Oncology Unit Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Francis J Hornicek
- Department of Orthopedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Patrick J Boland
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center and Weill College of Medicine, Cornell University, New York, New York
| | - Franklin H Sim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter C Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University Musculoskeletal Oncology Unit Mount Sinai Hospital, University of Toronto, Toronto, Canada
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Yang XY, Wei MT, Yang XT, He YZ, Hao Y, Zhang XB, Deng XB, Wang ZQ, Zhou ZQ. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis 2019; 21:138-155. [PMID: 30428157 DOI: 10.1111/codi.14471] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
AIM Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease. METHODS We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure. RESULTS Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.
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Affiliation(s)
- X Y Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - M T Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X T Yang
- Wound Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Y Z He
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Y Hao
- West China School of Public Health, Sichuan University, Chengdu, China
| | - X B Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X B Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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21
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Cahill C, Fowler A, Williams LJ. The application of incisional negative pressure wound therapy for perineal wounds: A systematic review. Int Wound J 2018; 15:740-748. [PMID: 29863305 DOI: 10.1111/iwj.12921] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/12/2018] [Accepted: 02/19/2018] [Indexed: 12/31/2022] Open
Abstract
Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.
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Affiliation(s)
- Caitlin Cahill
- Section of Colorectal and Minimally Invasive Surgery, Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amanda Fowler
- Section of Colorectal and Minimally Invasive Surgery, Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Lara J Williams
- Section of Colorectal and Minimally Invasive Surgery, Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects. Dis Colon Rectum 2017; 60:945-953. [PMID: 28796733 DOI: 10.1097/dcr.0000000000000875] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN This was a prospective case series. SETTINGS This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured. RESULTS The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.
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Prognostic Impact of Intra-abdominal/Pelvic Inflammation After Radical Surgery for Locally Recurrent Rectal Cancer. Dis Colon Rectum 2017; 60:827-836. [PMID: 28682968 DOI: 10.1097/dcr.0000000000000853] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The influence of postoperative infectious complications, such as anastomotic leakage, on survival has been reported for various cancers, including colorectal cancer. However, it remains unclear whether intra-abdominal/pelvic inflammation after radical surgery for locally recurrent rectal cancer is relevant to its prognosis. OBJECTIVE The purpose of this study was to evaluate factors associated with survival after radical surgery for locally recurrent rectal cancer. DESIGN The prospectively collected data of patients were retrospectively evaluated. SETTINGS This study was conducted at a single-institution tertiary care cancer center. PATIENTS Between 1983 and 2012, patients who underwent radical surgery for locally recurrent rectal cancer with curative intent at the National Cancer Center Hospital were reviewed. MAIN OUTCOME MEASURES Factors associated with overall and relapse-free survival were evaluated. RESULTS During the study period, a total of 180 patients were eligible for analyses. Median blood loss and operation time for locally recurrent rectal cancer were 2022 mL and 634 minutes. Five-year overall and 3-year relapse-free survival rates were 38.6% and 26.7%. Age (p = 0.002), initial tumor stage (p = 0.03), pain associated with locally recurrent rectal cancer (p = 0.03), CEA level (p = 0.004), resection margin (p < 0.001), intra-abdominal/pelvic inflammation (p < 0.001), and surgery period (p = 0.045) were independent prognostic factors associated with overall survival, whereas CEA level (p = 0.01), resection margin (p = 0.002), and intra-abdominal/pelvic inflammation (p = 0.001) were associated with relapse-free survival. Intra-abdominal/pelvic inflammation was observed in 45 patients (25.0%). A large amount of perioperative blood loss was the only factor associated with the occurrence of intra-abdominal/pelvic inflammation (p = 0.007). LIMITATIONS This study was limited by its retrospective nature and heterogeneous population. CONCLUSIONS Intra-abdominal/pelvic inflammation after radical surgery for locally recurrent rectal cancer is associated with poor prognosis. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.
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Systematic Review of Pelvic Exenteration With En Bloc Sacrectomy for Recurrent Rectal Adenocarcinoma: R0 Resection Predicts Disease-free Survival. Dis Colon Rectum 2017; 60:346-352. [PMID: 28177998 DOI: 10.1097/dcr.0000000000000737] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure. OBJECTIVE The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer. DATA SOURCES A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations. STUDY SELECTION Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma. MAIN OUTCOME MEASURE Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured. RESULTS A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection. LIMITATION The studies assessed by this review were retrospective case series and thus are subject to significant bias. CONCLUSION Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.
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Sammour T, Rodriguez-Bigas MA, Skibber JM. Locally Recurrent Disease Related to Anal Canal Cancers. Surg Oncol Clin N Am 2016; 26:115-125. [PMID: 27889030 DOI: 10.1016/j.soc.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Surgery for anal cancer is usually reserved for patients with persistent disease or local recurrence after definitive chemoradiation therapy. Patients with local recurrence should be re-evaluated for evidence of metastatic disease using positron emission tomography-computed tomography, and the local anatomy should be delineated with MRI. Eligible patients should undergo tailored surgery with the aim of achieving an R0 resection. Management is best undertaken within a specialized multidisciplinary setting. Careful patient selection and shared decision making are paramount for achieving acceptable patient-centered outcomes.
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Affiliation(s)
- Tarik Sammour
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, P.O. Box 301402, Houston, TX 77230-1402, USA
| | - Miguel A Rodriguez-Bigas
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, P.O. Box 301402, Houston, TX 77230-1402, USA
| | - John M Skibber
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, P.O. Box 301402, Houston, TX 77230-1402, USA.
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Althumairi AA, Canner JK, Gearhart SL, Safar B, Fang SH, Wick EC, Efron JE. Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 2016; 18:O260-6. [PMID: 27178168 DOI: 10.1111/codi.13384] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/24/2016] [Indexed: 02/08/2023]
Abstract
AIM The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.
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Affiliation(s)
- A A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - E C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Cuicchi D, Lecce F, Dalla Via B, De Raffele E, Mirarchi M, Cola B. Mortality and Morbidity. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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