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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Prognostic value of pre-operative mean corpuscular volume (MCV) in colorectal cancer

BACKGROUND

Mean corpuscular volume (MCV) has been shown to have some correlation to oncological outcomes in oesophageal cancer, with high pre-operative MCV associated with disease recurrence. A similar association has previously been reported in colorectal cancer.

AIMS

This study is aimed at investigating whether high MCV bears similar relation to post-operative outcome and disease recurrence in colorectal cancer (CRC).

METHODS

Patients undergoing elective CRC resection with curative intent between January 2008 and December 2019 were identified from our prospective database. Review of patient demographic details, American Society of Anaesthesiologists (ASA) grade, smoking and alcohol intake were performed. In addition, tumour location and staging, operation performed, pre-operative laboratory data and oncological management of each patient were noted. Post-operative morbidity (Clavien-Dindo (CD) score > 2), 30-day mortality, in-hospital mortality and cancer recurrence were examined and multivariable regression analysis was performed to predict these outcomes.

RESULTS

A total of 1,293 CRCs were resected, with 1,159 patients (89.7%) experiencing a hospital course without major morbidity (CD < 3). 30-day mortality rate was less than 1% (12/1293). There were 176 patients (13.6%) with recurrence at follow-up. When multivariable regression analysis was performed, high pre-operative MCV did not predict negative post-operative or oncological outcomes.

CONCLUSION

MCV does not appear to be an independent prognostic factor for outcomes following elective CRC resection.

Extramural venous invasion (EMVI) in colorectal cancer is associated with increased cancer recurrence and cancer-related death

INTRODUCTION

Colorectal cancer (CRC) outcomes vary depending on tumour biology, with several features used to predict disease behaviour. Extramural venous invasion (EMVI) is associated with negative outcomes and its presence has been established as an indicator of more aggressive disease in CRC.

METHODS

A prospectively maintained database was examined for patients undergoing curative resection for non-metastatic CRC between 2012 and 2018 in a tertiary institution. Clinicopathological factors were compared to assess their impact on recurrence, all-cause mortality and cancer-related death. Kaplan Meier analysis of the association between EMVI and these endpoints was performed, and univariable and multivariable analysis was carried out to establish the relationship of predictive factors in oncological outcomes.

RESULTS

Eighty-eight (13.5%) of 654 patients developed recurrence. The mean time to recurrence was 19.8 ± 13.5 months. There were 36 (5.5%) cancer-related deaths at a mean duration of follow-up of 46.3 ± 21.6 months. Two hundred and sixty-six patients had extramural venous invasion (40.7%). EMVI was significantly associated with reduced overall recurrence-free survival, systemic recurrence-free survival, and increased cancer-related death on univariate analysis (p < 0.001 for all, Fig. 1), and multivariable analysis (OR 1.8 and 2.1 respectively, p < 0.05 for both).

CONCLUSION

EMVI is associated with a poor prognosis, independent of stage, nodal status and other histopathological features. The presence of EMVI should be strongly considered as an indication for adjuvant therapy.

Abstract P1-02-07: Breast density, metabolic syndrome and body composition in breast cancer

Background- The metabolic syndrome (MetS) is prevalent among post-menopausal breast cancer patients and is associated with increased breast cancer risk. Mammographic breast density (BD) is also positively associated with increased breast cancer risk. The relationship between MetS and mammographic BD is unclear and requires further investigation.

Aim- The aim of this study was to examine the relationship between the MetS and its component features with breast density.

Methods - 112 post-menopausal women with breast cancer were recruited. Body composition (Body Mass Index (BMI), waist circumference (WC)) was measured objectively in participants prior to surgery. Metabolic profiles were measured in blood taken from participants prior to surgery. MetS was defined according to the International Diabetes Federation (IDF) criteria. BD was classified according to the Breast Imaging Reporting and Data System (BI-RADS). Participants were categorised into those with 'Dense' (BI-RADS score 3 or 4) or 'Less Dense' (BI-RADS score 1 or 2) breasts. Group means were compared using unpaired t-tests for parametric or Mann Whitney tests for non-parametric data. Categorical data was analysed using Fisher's exact test or Chi squared test as appropriate.

Results - An inverse relationship was observed between measures of adiposity and BD. Participants with 'dense' (BI-RADS 3/4) breasts had significantly lower BMI(p=0.0034), waist circumference(p=0.0007), systolic blood pressure(p= 0.03), circulating insulin level(p=0.009) and glycated haemoglobin(p=0.008) than those with 'less dense' (BI-RADS 1/2) breasts. HDL was significantly higher in those with 'dense' versus those with 'less dense' breasts(p= 0.03). participants with 'less dense' breasts were significantly more likely to be insulin resistant (HOMA-IR ≥2) than those with 'dense breasts' (50.6% versus 20% respectively); p=0.01.

Other components of the MetS (Serum triglycerides, glucose and diastolic blood pressure) did not differ significantly between participants with 'dense' and 'less dense' breasts. No differences in overall survival were observed between participants with 'Dense' versus those with 'Less Dense' breasts (P=0.93).

Conclusion - Although both MetS and BD are positively associated with breast cancer risk; it is unlikely that the MetS is related to an increase in breast cancer risk through a mechanism involving BD. Further work on this study is currently underway and will involve adjusting for potential confounders including age and BMI as well as examining the relationship between MetS and BD in pre-menopausal breast cancer patients.

Citation Format: Shokuhi P, McGarrigle SA, Sullivan CJ, Boyle T, Al-azawi D, O'Keeffe S, Kennedy J, Connolly EM. Breast density, metabolic syndrome and body composition in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-02-07.