Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis

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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Key Words

• Abdominoperineal resection
• Perineal complications
• Surgical oncology
• Vertical rectus abdominis myocutaneous flap

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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
Niall J O'Sullivan Department of Surgery, St. James's Hospital, Dublin, Ireland
Benjamin Mac Curtain Department of Surgery, St John of God Subiaco Hospital, Perth, Australia
Caitlin Waters Department of Surgery, Fiona Stanley Hospital, Perth, Australia
Alannah Murray Department of Surgery, St. James's Hospital, Dublin, Ireland
Christina E Buckley Department of Plastics, 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
Paul H McCormick 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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A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis

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.

Laparoscopic Oblique Rectus Abdominis Myocutaneous Flap Harvest for Perineal Reconstruction After Abdominoperineal Resection

BACKGROUND

Treatment of perineal defects after abdominoperineal resection or salvage surgery for either locally advanced rectal cancer or anal carcinoma can be challenging. Myocutaneous flap reconstruction has proven to reduce perineal morbidity and abscess formation in the pelvis; however, it is associated with significant donor-site morbidity. To our knowledge, this is the first report of a laparoscopic oblique rectus abdominis myocutaneous flap harvesting for perineal reconstruction. This technical note aimed to demonstrate the feasibility of the technique.

IMPACT OF INNOVATION

Introduction of a laparoscopic technique in harvesting of this flap can potentially further reduce morbidity associated with this flap creation by minimizing abdominal wall trauma and obviating the need for laparotomy for tunneling of the flap intra-abdominally.

TECHNOLOGY, MATERIALS, AND METHODS

This report describes a technique using a 6-port laparoscopy, in which the harvesting of the myocutaneous flap was performed after a standardized abdominoperineal resection. The flap itself is passed through the rectus sheath toward the pelvis with the help of a retractor.

PRELIMINARY RESULTS

Two patients successfully underwent a laparoscopic oblique rectus abdominis flap reconstruction after abdominoperineal resection.

CONCLUSION AND FUTURE DIRECTIONS

This report describes our initial experience with laparoscopic harvesting of an oblique rectus abdominis flap for perineal reconstruction after abdominoperineal resection. We believe the technique is easy and reproducible for laparoscopic surgeons and can reduce donor-site morbidity. However, further studies will be needed to confirm this observation.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds

BACKGROUND

Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects.

METHODS

Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared.

RESULTS

Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds.

CONCLUSIONS

Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Feasibility of Perineal Defect Reconstruction with Simplified Fasciocutaneous Inferior Gluteal Artery Perforator (IGAP) Flaps after Tumor Resection of the Lower Rectum: Incidence and Outcome in an Interdisciplinary Approach

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) is a relatively new surgical technique for low rectal cancers, enabling a more radical approach than conventional abdominoperineal excision (APE) with a potentially better oncological outcome. To date, no standard exists for reconstruction after extended or extralevator approaches of abdominoperineal (ELAPE) resection for lower gastrointestinal cancer or inflammatory tumors. In the recent literature, techniques with myocutaneous flaps, such as the VY gluteal flap, the pedicled gracilis flap, or the pedicled rectus abdominis flaps (VRAM) are primarily described. We propose a tailored concept with the use of bilateral adipo-fasciocutaneous inferior gluteal artery perforator (IGAP) advancement flaps in VY fashion after ELAPE surgery procedures. This retrospective cohort study analyzes the feasibility of this concept and is, to our knowledge, one of the largest published series of IGAP flaps in the context of primary closure after ELAPE procedures.

METHODS

In a retrospective cohort analysis, we evaluated all the consecutive patients with rectal resections from Jan 2017 to Sep 2021. All the patients with abdominoperineal resection were included in the study evaluation. The primary endpoint of the study was the proportion of plastic reconstruction and inpatient discharge.

RESULTS

Out of a total of 560 patients with rectal resections, 101 consecutive patients with ELAPE met the inclusion criteria and were included in the study evaluation. The primary direct defect closure was performed in 72 patients (71.3%). In 29 patients (28.7%), the defect was closed with primary unilateral or bilateral IGAP flaps in VY fashion. The patients' mean age was 59.4 years with a range of 25-85 years. In 84 patients, the indication of the operation was lower rectal cancer or anal cancer recurrence, and non-oncological resections were performed in 17 patients. Surgery was performed in a minimally invasive abdominal approach in combination with open perineal extralevatoric abdominoperineal resection (ELAPE) and immediate IGAP flap reconstruction. The rate of perineal early complications after plastic reconstruction was 19.0%, which needed local revision due to local infection. All these interventions were conducted under general anesthesia (Clavien-Dindo IIIb). The mean length of the hospital stay was 14.4 days after ELAPE, ranging from 3 to 53 days.

CONCLUSIONS

Since radical resection with a broad margin is the standard choice in primary, sphincter-infiltrating rectal cancer and recurrent anal cancer surgery in combination with ELAPE, the choice technique for pelvic floor reconstruction is under debate and there is no consensus. Using IGAP flaps is a reliable, technical, easy, and safe option, especially in wider defects on the pelvic floor with minimal donor site morbidity and an acceptable complication (no flap necrosis) rate. The data for hernia incidence in the long term are not known.

The impact of repeated bladder surgery on successful bladder neck closure in classic bladder exstrophy: The role of mucosal violations

INTRODUCTION

Restoration of genitourinary anatomy with functional urinary continence is the reconstruction aim is the exstrophy-epispadias complex (EEC). In patients who do not achieve urinary continence or those who are not a candidate for bladder neck reconstruction (BNR), bladder neck closure (BNC) is considered. Interposing layers including human acellular dermis (HAD) and pedicled adipose tissue are routinely placed between the transected bladder neck and distal urethral stump to reinforce the BNC and minimize failure due to fistula development from the bladder.

OBJECTIVE

The aim of this study was to review classic bladder exstrophy (CBE) patients who underwent BNC to identify predictors of BNC failure. Specifically, we hypothesize that increased operations on the bladder urothelium leads to a higher rate of urinary fistula.

STUDY DESIGN

CBE patients who underwent BNC were reviewed for predictors of failed BNC which was defined as bladder fistula development. Predictors included prior osteotomy, interposing tissue layer use and number of previous bladder mucosal violations (MV). A MV was defined as a procedure when the bladder mucosa was opened or closed for: exstrophy closure(s), BNR, augmentation cystoplasty or ureteral re-implantation. Predictors were evaluated using multivariate logistic regression.

RESULTS

A total of 192 patients underwent BNC of which 23 failed. Patients were more likely to develop a fistula with a wider pubic diastasis at time of primary exstrophy closure (4.4 vs 4.0 cm, p=0.0016), have failed exstrophy closure (p=0.0084), or have 3 or more MVs before BNC (p=0.0002). Kaplan-Meier analysis of fistula-free survival after BNC, demonstrated an increased fistula rate with additional MVs (p=0.0004, Figure 1). MVs remained significant on multivariate logistic regression analysis with a per-violation odds ratio of 5.1 (p<0.0001). Of the 23 failed BNC's, 16 were surgically closed including 9 using a pedicled rectus abdominis muscle flap which was secured to the bladder and pelvic floor.

CONCLUSION

This study conceptualized MVs and their role in bladder viability. Increased MVs confer an increased risk of failed BNC. When considering BNC, CBE patients with 3 or more prior MVs may benefit from a pedicled muscle flap, in addition to HAD and pedicled adipose tissue, to prevent fistula development by providing wellvascularized coverage to further reinforce the BNC.

Gracilis Flap Reconstruction After Proctocolectomy for Malignancy and Inflammatory Bowel Disease

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.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis

BACKGROUND

Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm.

METHODS

A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature.

RESULTS

Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates.

CONCLUSION

Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: A retrospective cohort study

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.

Perineal Reconstruction With the Profunda Artery Perforator Flap

BACKGROUND

Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction.

METHODS

A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications.

RESULTS

Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients.

CONCLUSIONS

The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects.

Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection

BACKGROUND

The vertical rectus abdominis flap is considered the gold standard in perineal reconstruction after oncological abdominoperineal resection; however, it has a nonnegligible donor site morbidity. The anterolateral thigh flap offers reliable soft tissue coverage.

OBJECTIVE

The aim was to analyze long-term outcomes of composite anterolateral thigh-vastus lateralis flaps in oncological abdominoperineal resections.

DESIGN

We conducted a retrospective cohort analysis of a prospectively maintained database.

SETTINGS

This study was conducted in the Lausanne University Hospital. Annually, approximately 10 oncological abdomioperineal resections are performed. Literature reports 7% to 20% of patients undergoing abdominoperineal resection require flap reconstruction; in our institution, approximately 2 patients with large defects after abdominoperineal resections required reconstruction.

PATIENTS

Twenty-nine pedicled anterolateral thigh-vastus lateralis flaps in 27 consecutive patients (mean age 63 years +/-11.2, 23 with radiochemotherapy) after abdominoperineal resection to cover large defects (median 190 cm2, 48-600 cm2) were analyzed.

INTERVENTION

Pedicled composite anterolateral thigh-vastus lateralis flaps were performed after oncological abdominoperineal resection.

MAIN OUTCOME MEASURES

Descriptive statistical analysis was conducted. Short- and long-term outcomes were analyzed, univariate and multivariate analyses were performed. Median follow-up was 16 months (12-48 months).

RESULTS

Flap-related postoperative complications occurred in 16 flaps; flap-survival was 100%. Multivariate logistic analysis identified initial defect size as predictive for complications. Patients with larger defects (≥ 190 cm2) had higher complication rates (p = 0.006). Long-term analysis revealed 3 chronic fistulae, 2 tumor recurrences, 1 flap dysesthesia, and one perineal acne inversa.

LIMITATIONS

Limitations include retrospective analysis, selection bias, and lacking a control group. Sample size limits statistical power.

CONCLUSIONS

The pedicled anterolateral thigh-vastus lateralis flap offers reliable, stable tissue with low morbidity and good long-term outcomes. Complications compared favorably with current literature describing perineal reconstructions with rectus abdominis flaps. The composite anterolateral thigh flap is a valid alternative without the setback of abdominal donor site morbidity. See Video Abstract at http://links.lww.com/DCR/B757.RESULTADOS DEL COLGAJO COMPUESTO ANTEROLATERAL DE MUSLO PARA LA RECONSTRUCCIÓN PERINEAL DESPUÉS DE LA RESECCIÓN ABDOMINOPERINEAL POST ONCOLÓGICAANTECEDENTES:El colgajo vertical de recto abdominal se considera el estándar de oro en la reconstrucción perineal después de la resección abdominoperineal oncológica, sin embargo, tiene una morbilidad no despreciable en el sitio donante. El colgajo anterolateral del muslo ofrece una cobertura confiable de los tejidos blandos.OBJETIVO:El objetivo fue analizar los resultados a largo plazo de los colgajos compuestos anterolaterales del muslo - vasto lateral - en resecciones abdominoperineales oncológicas.DISEÑO:Realizamos un análisis, retrospectivo, de tipo cohorte, de una base de datos mantenida prospectivamente.AJUSTES:Este estudio fue realizado en el hospital universitario de Lausanne. Anualmente se realizan aproximadamente 10 resecciones abdominoperineales oncológicas. La literatura reporta que entre el 7 y el 20% de los pacientes que se someten a una resección abdominoperineal requieren de reconstrucción con colgajo; en nuestra institución, aproximadamente 2 pacientes con grandes defectos tras la resección abdominoperineal requirieron reconstrucción.PACIENTES:Fueron analizados veintinueve colgajos pediculados anterolaterales de muslo - vasto lateral - en 27 pacientes consecutivos (edad media 63 años +/- 11,2, 23 con radio quimioterapia) después de la resección abdominoperineal para cubrir defectos grandes (mediana 190 cm2, 48-600 cm2).INTERVENCIÓN:Tras la resección abdominoperineal oncológica se realizaron colgajos pediculados compuestos anterolaterales de muslo - vasto lateral.PRINCIPALES MEDIDAS DE RESULTADO:Fue realizado un análisis estadístico descriptivo. Fueron analizados los resultados a corto y largo plazo - fueron realizados así mismo análisis uni y multivariados. La mediana de seguimiento fue de 16 meses (12-48 meses).RESULTADOS:Complicaciones postoperatorias relacionadas con el colgajo ocurrieron en 16 colgajos, la supervivencia del colgajo fue del 100%. El análisis logístico multivariado identificó al tamaño del defecto inicial como predictor de complicaciones. Aquellos pacientes con defectos más grandes (≥190 cm2) tuvieron mayores tasas de complicaciones (p = 0,006). El análisis a largo plazo reveló tres fístulas crónicas, dos recidivas tumorales, una disestesia de colgajo y un acné perineal inverso.LIMITACIONES:Las limitaciones incluyen análisis retrospectivo, sesgo de selección y falta de grupo de control. El tamaño de la muestra limita el poder estadístico.CONCLUSIONES:El colgajo pediculado anterolateral de muslo - vasto lateral - ofrece tejido confiable y estable con baja morbilidad y buenos resultados a largo plazo. Los resultados de las complicaciones se mostraron favorables con respecto a la literatura actual que describe reconstrucciones perineales con colgajos de recto abdominal. El colgajo compuesto anterolateral de muslo es una alternativa válida sin el revés de la morbilidad del sitio donante abdominal. Consulte Video Resumen en http://links.lww.com/DCR/B757. (Traducción-Dr. Osvaldo Gauto).

Vaginal reconstruction using a gluteal transposition flap after abdominoperineal excision for anorectal malignancy

The purpose of this study is to present and evaluate a surgical method using gluteal flap for combined perineal and vaginal reconstruction after abdominoperineal excision (APE) with partial vaginectomy for anorectal malignancy. The method is a two-centre study of consecutive patients undergoing APE including partial vaginectomy for anorectal tumours, with immediate combined perineal and vaginal reconstruction using gluteal flaps. Follow-up data were retrieved via retrospective review of medical records, questionnaires and gynaecological examinations. Some 34 patients fulfilled the inclusion criteria. At the time of follow-up, 14 (78%) of the 18 patients alive responded to questionnaires. Seven (50%) of the survey responders agreed to undergo gynaecological examination. Major flap-specific complications (Clavien–Dindo > 2) were observed in 3 (9%) patients. Among survey responders, 11 (79%) had been sexually active preoperatively of which five (45%) resumed sexual activity postoperatively and three (27%) resumed vaginal intercourse. These three patients had all implemented an active vaginal health promotion strategy postoperatively. Perineo-vaginal reconstruction using gluteal flap after extended APE for anorectal malignancy is feasible. Although comparable to other methods of reconstruction, the rate of perineo-vaginal complications is high and post-operative sexual dysfunction is substantial. Postoperative strategies for vaginal health promotion may improve sexual function after vaginal reconstruction.

System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection

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.

Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer

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.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction

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.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods

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.

Dorsal approach with tailored partial sacrectomy and gluteal V-Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report

Background

Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue.

Case presentations

Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity.

Conclusion

The dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

BACKGROUND

 Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications.

METHODS

 A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed.

RESULTS

 Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm². The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications.

CONCLUSION

 In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

Ten-Year experience with vertical rectus abdominis myocutaneous flap for reconstruction of abdominoperineal resection defects

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.

A comparison of oncological outcomes after abdominoperineal excision before and after the implementation of a selective perineal flap closure program

BACKGROUND AND OBJECTIVES

Abdominoperineal excision (APE) is the operation chosen when a patient has low rectal cancer unamenable to sphincter preserving surgery. Perineal flap reconstruction is associated with less wound morbidity but little is known about oncological outcomes. The objective was to compare outcomes in patients undergoing APE before and after the introduction of a program that utilized flap reconstruction of the perineum.

METHODS

A retrospective review of a prospectively maintained database was performed. Patients who underwent APE followed by primary closure or flap reconstruction between 1998 and 2018 were selected. The cohorts were divided according to the implementation of the flap reconstruction program in July 2009. Clinicopathological data, recurrence and survival were compared between the cohorts.

RESULTS

One hundred and forty nine patients underwent APE for rectal adenocarcinoma between 1998 and 2018. There were 57 patients in the pre-flap era and 92 in the post-flap era. Forty-six patients underwent flap reconstruction in the latter cohort (50%). More patients in the post-flap era underwent neoadjuvant chemoradiotherapy (85.9% vs. 63.2%; p < .01). Margin positivity rates decreased from 21.1% in the pre-flap era to 10.9% in the post-flap era (p = .10) and there was an associated improvement in incidence and time to local recurrence (p = .03).

CONCLUSION

The use of perineal flap reconstruction is associated with a longer median time to local recurrence. Perineal flap reconstruction may contribute to reduced margin positivity.

Wide posterior gluteal-thigh propeller flap for reconstruction of perineal defects

INTRODUCTION

With increasing popularity of minimally invasive approaches to abdominoperineal resection (APR), thigh-based flaps are becoming the preferred option for reconstruction. The gluteal-thigh flap provides sufficient bulk, albeit with a high complication rate. We reevaluated the vascularization and design of the gluteal-thigh flap. The purpose of this study is to highlight the importance of the vascularization of the posterior thigh skin by the descending branch of the inferior gluteal artery (IGA) and the profunda femoris artery (PFA) perforators to design a more reliable and versatile gluteal thigh flap. This flap is indicated in selected cases in which use of vertical rectus abdominis musculocutaneous flap is not feasible.

METHODS

Eleven fresh cadavers were used. The course, distribution, and diameter of IGA and PFA perforators were recorded. A wide posterior gluteal-thigh propeller flap (WPGTPF) was designed including the distance between the ischiatic tuberosity and greater trochanter; and extending it to within 8 cm of the popliteal fossa to improve flap reliability. Ten patients (mean age of 58.7 ± 10.6 years) underwent APR due to anal cancer (2) and rectal cancer (8); the approach was open in 3, laparoscopic in 6, and robotic in 1. All 10 patients received unilateral flap with a width of 12 ± 3.3 cm and surface of 405.5 ± 175.9 cm² .

RESULTS

The descending branch of the IGA was dominant in 72.7% of the specimens. In 22.7% of the specimens, the pedicle of the flap derived from the first or second PFA perforators. In one case, there was a double vascularization. Descending branch of the IGA was mapped at 46 ± 7.96 mm on the X-axis (horizontal line from the ischial tuberosity [IT] to the greater trochanter) and -12.1 ± 17.9 mm on the Y-axis (vertical line from the IT to the Medial Femoral condyle). Its average caliber measured 2.18 ± 0.3 mm. The first and second PFA perforators were located at 101.6 ± 17.9 mm and 104.5 ± 15.5 mm on the X-axis; 35.9 ± 27.1 mm and 89.2 ± 37.6 mm on the Y-axis. Their average diameters were 1.84 ± 0.41 mm and 1.48 ± 0.3 mm. In two cases, the flap was based on the first PFA perforator, the rest were on the descending branch of the IGA. Neither complete nor partial flap necrosis was observed. One patient developed coccyx osteomyelitis treated and resolved with bone debridement and one patient developed a seroma of the lateral thigh that was treated conservatively. Three patients underwent a debulking procedure by a combination of liposuction and resection to improve the gluteal symmetry. All ten flaps survived completely.

CONCLUSIONS

Harvest of a wide flap that includes the PFA perforators and implementation of the propeller design increase the survival and versatility of the flap.

MRI of surgical flaps in pelvic reconstructive surgery: a pictorial review of normal and abnormal findings

Surgical flaps are commonly used for pelvic reconstruction in a subgroup of patients with locally advanced or recurrent anorectal and gynecologic malignancies and following complications of pelvic irradiation. Surgical scenarios where flaps may be placed include (but are not limited to) extended or radical abdominal perineal resection (APR) and total pelvic exenteration (PE). Surgical flaps in pelvic reconstruction serve several functions, including reducing dead space and providing structural support, facilitating wound closure and cosmetic appearance, enhancing the postsurgical healing process, protecting anastomoses and helping to prevent adhesions of organs and viscera to adjacent structures and the pelvic side wall. The most commonly used surgical flaps in pelvic reconstruction surgery include the VRAM (Vertical Rectus Abdominis Muscle), MRAM (Modified Rectus Abdominis Myocutaneous flap), gracilis, sartorius and omental flaps. Surgical flaps can be mistaken for recurrent or residual tumor by radiologists who are not familiar with the appearance or surgical methods of flap placement, since flaps may have a mass-like appearance on cross sectional imaging, including CT and MRI. Recurrent neoplasm may be difficult to differentiate from postoperative changes of flap placement and associated postsurgical anatomic distortion. This review article focuses on understanding the nuances of surgically placed pelvic flaps and identifying their normal and abnormal appearances on magnetic resonance imaging (MRI) along a time continuum. Postsurgical complications, including hematoma, postoperative fluid collections, infection, ischemia, and necrosis as well as tumor recurrence on the initial and follow-up magnetic resonance imaging are illustrated and discussed.

Transpelvic Oblique Rectus Abdominis Myocutaneous Flap With Preservation of the Rectus Sheath

BACKGROUND

Perineal reconstructive surgery is an effective procedure to decrease the morbidity associated with extensive abdominoperineal resection in the treatment of advanced low rectal and anal malignancies. Rectus abdominis myocutaneous flaps are often utilized in perineal reconstruction with excellent results. However, the main disadvantages are donor-site morbidity and the need for an open procedure after laparoscopic resection, requiring larger incisions with a resultant increase in postoperative pain. Herein, we describe a modified oblique rectus abdominis myocutaneous flap technique that allows sparing of the rectus sheath and the linea alba.

TECHNIQUE

We followed the 3 stages regularly described for the procedure: 1) abdominoperineal resection with simultaneous abdominal and perineal team approach, and removal of the specimen through the perineal wound; 2) right oblique rectus abdominis myocutaneous flap with inferior epigastric pedicle, and release of the rectus muscle from its aponeurotic sheath through the skin paddle incision and transposition of the oblique rectus abdominis myocutaneous flap through an incision in the transversalis fascia; and 3) perineal reconstruction by sutures of the skin paddle to the perineal wound skin edges.

RESULTS

Release of the rectus muscle within its sheath through the incision in the skin paddle turned out to be a simple surgical procedure, without the need of specialized surgical instruments or additional incisions. There were no complications during the postoperative recovery. Our patient was pain-free 1 month after the surgery, with a well-healed flap and abdominal scar.

CONCLUSION

Performance of an oblique rectus abdominis myocutaneous flap that is specifically fitted for the perineal defect after abdominoperineal resection, with muscle dissection performed through the skin paddle incision and transposition into the pelvis through the transversalis fascia, offers good functional outcome while minimizing damage to the abdominal wall.

Perineal wound closure using gluteal turnover flap or primary closure after abdominoperineal resection for rectal cancer: study protocol of a randomised controlled multicentre trial (BIOPEX-2 study)

Background

Abdominoperineal resection (APR) for rectal cancer is associated with high morbidity of the perineal wound, and controversy exists about the optimal closure technique. Primary perineal wound closure is still the standard of care in the Netherlands. Biological mesh closure did not improve wound healing in our previous randomised controlled trial (BIOPEX-study). It is suggested, based on meta-analysis of cohort studies, that filling of the perineal defect with well-vascularised tissue improves perineal wound healing. A gluteal turnover flap seems to be a promising method for this purpose, and with the advantage of not having a donor site scar. The aim of this study is to investigate whether a gluteal turnover flap improves the uncomplicated perineal wound healing after APR for rectal cancer.

Methods

Patients with primary or recurrent rectal cancer who are planned for APR will be considered eligible in this multicentre randomised controlled trial. Exclusion criteria are total exenteration, sacral resection above S4/S5, intersphincteric APR, biological mesh closure of the pelvic floor, collagen disorders, and severe systemic diseases. A total of 160 patients will be randomised between gluteal turnover flap (experimental arm) and primary closure (control arm). The total follow-up duration is 12 months, and outcome assessors and patients will be blinded for type of perineal wound closure. The primary outcome is the percentage of uncomplicated perineal wound healing on day 30, defined as a Southampton wound score of less than two. Secondary outcomes include time to perineal wound closure, incidence of perineal hernia, the number, duration and nature of the complications, re-interventions, quality of life and urogenital function.

Discussion

The uncomplicated perineal wound healing rate is expected to increase from 65 to 85% by using the gluteal turnover flap. With proven effectiveness, a quick implementation of this relatively simple surgical technique is expected to take place.

Trial registration

The trial was retrospectively registered at Clinicaltrials.gov NCT04004650 on July 2, 2019.

Factors associated with the use of vertical rectus abdominus myocutaneous flap reconstruction following abdominoperineal resection for anorectal cancer

BACKGROUND AND OBJECTIVES

Following abdominoperineal resection (APR), primary closure of the perineal defect is often possible. Some patients, however, require flap reconstruction. Identifying these patients preoperatively is critical to facilitate comprehensive patient counseling and optimize surgical efficacy.

METHODS

A retrospective review of patients undergoing APR over a 10-year period was performed to identify predictive factors for patients requiring reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap as opposed to primary closure. Student's t and Fisher's exact tests were utilized for statistical analysis.

RESULTS

A total of 158 patients underwent APR, 29 of whom (18%) required a VRAM flap. A higher average skin resection area was seen among those requiring flap reconstruction (P < .0001). Flap reconstruction was also associated with current smoking status (P = .0197), anal tumor location (P < .0001), and neoadjuvant radiation (P = .0457). Although not statistically significant, average tumor diameter was larger in the VRAM flap group compared with the primary closure group.

CONCLUSIONS

While the appropriate method of closure for those undergoing APR should be considered on an individual case basis, patients who smoke, have a tumor located at the anus, or require large skin resection are more likely to need flap reconstruction.

Interdisciplinary Surgical Approaches in Vaginal and Perineal Reconstruction of Advanced Rectal and Anal Female Cancer Patients

Relapsing or far advanced rectal and anal cancers remain difficult to treat and require interdisciplinary approaches. Due to modern standard protocols all patients receive irradiation and neoadjuvant chemotherapy-and in case of a relapse a second irradiation-rendering the surgical site prone to surgical site infections and oftentimes long lasting sinus and septic complications after exenteration in the pelvis. Despite an improved overall survival rate in these patients the downside of radical tumor surgery in the pelvis is a major loss of quality of life, especially in women when parts of the vagina need to be resected. Derived from our experince with over 300 patients receiving pelvic and perineal reconstruciton with a transpelvic vertical rectus abdominis myocutaneous (tpVRAM) flap we studied the impact of this surgical technique on the outcomes of female patients with or without vaginal reconstruction following pelvic exenteration. We found out that the tpVRAM flap is reliably perfused and helps to reduce long term wound healing desasters in the irradiated perineal/vaginal/gluteal region.

Immediate Reconstruction After Colorectal Cancer Resection: A Cohort Analysis Through the National Surgical Quality Improvement Program and Outcomes Review

BACKGROUND

Colorectal cancer is one of the most common and fatal malignancies in the United States. When localized to the distal gastrointestinal tract, surgical therapy includes abdominoperineal resection (APR) or pelvic exenteration (PEX). Subsequent ablative defects are considerable, impart concerning morbidity, and often necessitate autologous reconstruction. The aim of this study was to assess postoperative outcomes after reconstruction of APR and PEX defects.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (2005-2017) was queried for patients undergoing APR for lower gastrointestinal malignancies with concurrent autologous reconstructions. Cases of disseminated cancer were excluded. Postoperative adverse event profiles, including rates of wound and systemic complications, were evaluated. Multivariate regression analysis controlling for age, sex, body mass index, and operative time was performed to calculate adjusted odds ratios (ORs).

RESULTS

A total of 1309 patients were identified as undergoing APR/PEX with concomitant reconstruction. The majority (96.9%) of reconstructions consisted of muscle, myocutaneous, fasciocutaneous, or omental pedicled flaps. Of the cohort, 45.7% experienced at least 1 all-cause complication within 30-days of the procedure. Having a limited or moderate frailty (frailty index of "1" or "2") was identified as a predictor of all-cause complications [OR, 1.556; 95% confidence interval (CI), 1.187-2.040, P = 0.001; and OR, 1.741; 95% CI, 1.193-2.541, P = 0.004, respectively], whereas smoking was a predictor of wound complications (OR, 1.462; 95% CI, 1.070-1.996, P = 0.017) and steroid use was a predictor of mild systemic complications (OR, 2.006; 95% CI, 1.058-3.805, P = 0.033).

CONCLUSION

Anorectal cancer resection often necessitates reconstruction secondary to postexenteration perineal defects. The incidence of postoperative complications is relatively high, and several risk factors are identified to help refine patient optimization.

Risk factors for delayed perineal wound healing and its impact on prolonged hospital stay after abdominoperineal resection

Background

Perineal wound complications are a long-lasting issue for abdominoperineal resection (APR) patients. Complication rates as high as 60% have been reported, with the most common complication being delayed perineal wound healing. The aim of this study was to identify risk factors for delayed perineal wound healing and its impact on prolonged hospital stay.

Methods

We included low rectal tumor patients who underwent APR at a referral medical center from April 2002 to December 2017; a total of 229 patients were included. The basic characteristics and surgical outcomes of the patients were analyzed to identify risk factors for delayed perineal wound healing (> 30 days after APR) and prolonged hospital stay (post-APR hospital stay > 14 days).

Results

All patients received primary closure for their perineal wound. The majority of patients were diagnosed with adenocarcinoma (N = 213, 93.1%). In the univariate analysis, patients with hypoalbuminemia (albumin < 3.5 g/dL) had an increased risk of delayed wound healing (39.5% vs. 60.5%, P = 0.001), which was an independent risk factor in the multivariable analysis (OR 2.962, 95% CI 1.437–6.102, P = 0.003). Patients with delayed wound healing also had a significantly increased risk of prolonged hospital stay (OR 6.404, 95% CI 3.508–11.694, P < 0.001).

Conclusions

Hypoalbuminemia was an independent risk factor for delayed wound healing, which consequently led to a prolonged hospital stay. Further clinical trials are needed to reduce the incidence of delayed perineal wound healing by correcting albumin levels or nutritional status before APR.

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer

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.

Propensity Score Adjusted Comparison of Pelviperineal Morbidity With and Without Omentoplasty Following Abdominoperineal Resection for Primary Rectal Cancer

BACKGROUND

Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear.

OBJECTIVE

This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer.

DESIGN

This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding.

SETTING

The study was undertaken in 2 teaching hospitals and 1 university hospital.

PATIENTS

Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included.

MAIN OUTCOME MEASURES

The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period.

RESULTS

Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45-1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46-3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation.

LIMITATIONS

This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts.

CONCLUSION

In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918.

Inguinal Reconstruction Using Pedicled Rectus Abdominis Flap: A Useful Option for the Application of Radiotherapy

Given their high rate of complications, radical surgical procedures of anorectal and gynecological tumors require a reliable and individualized reconstruction. The latter is influenced by the frequent indication of adjuvant chemo/radiotherapy that they present. We describe the case of a patient with medical history of vulvar carcinoma that required radical surgery and bilateral inguinal lymphadenectomy. Because of the stage of the tumor, the application of postoperative radiotherapy was clinically indicated; however, after surgery, the patient developed bilateral inguinal ulcers that made postoperative radiotherapy application impossible. Using a radical surgical approach in combination with postoperative radiotherapy increases survival in patients with these types of tumors. Therefore, delaying its use because of wound complications or inadequate reconstruction cannot be justified. The pedicled abdominal rectus flap is an excellent option for this purpose in patients with moderate- to large-sized defects.