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Benedict KC, Songcharoen SJ, Stephens KL, Winter AL, Edwards SR, Campbell CA, Arnold PB. Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds. J Plast Reconstr Aesthet Surg 2023; 84:514-520. [PMID: 37418850 DOI: 10.1016/j.bjps.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 03/29/2023] [Accepted: 06/06/2023] [Indexed: 07/09/2023]
Abstract
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.
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Affiliation(s)
- Katherine C Benedict
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA.
| | - Somjade J Songcharoen
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| | - Kristin L Stephens
- University of Virginia, Department of Plastic Surgery, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - Anna L Winter
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| | - Shelley R Edwards
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
| | - Christopher A Campbell
- University of Virginia, Department of Plastic Surgery, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - Peter B Arnold
- University of Mississippi Medical Center, Division of Plastic and Reconstructive Surgery, 2500 North State Street, Jackson, MS 39216, USA
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Kim S, Kang SI, Kim S, Kim JH. Clinical effectiveness of omental transposition in facilitating perineal wound healing after abdominoperineal resection: a systematic review. Yeungnam Univ J Med 2021; 38:219-224. [PMID: 33557001 PMCID: PMC8225496 DOI: 10.12701/yujm.2020.00871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/13/2021] [Indexed: 11/06/2022] Open
Abstract
Background Omental transposition has been used to facilitate perineal wound healing in patients undergoing abdominoperineal resection (APR). However, there is no high-level evidence supporting the effectiveness of omental transposition in this regard. This study aimed to investigate the clinical efficacy of omental transposition in facilitating perineal wound healing after APR. Methods In this systematic review, we systematically searched the PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases for literature regarding the topic of our study. Studies published since the inception of each database were considered for review. The outcomes of interest were the perineal wound healing rate at 1 and 3 months postoperatively, perineal wound infection rate, and perineal wound healing period. Results Of the 1,923 studies identified, four articles representing 819 patients (omental transposition patients, n=295) were included in the final analysis. The wound healing rates at 1 and 3 months postoperatively in the omental transposition group (68.5% and 79.7%, respectively) did not significantly differ from those in the control group (57.4% and 78.7%, respectively) (p=0.759 and p=0.731, respectively). Perineal wound infection and chronic wound complication rates, including sinus, dehiscence, and fistula rates, also did not significantly differ between the omental transposition (8% and 7%, respectively) and control (11% and 7%, respectively) groups (p=0.221 and p=0.790, respectively). Conclusion Our results suggest that omental transposition does not affect perineal wound healing in patients who undergo APR.
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Affiliation(s)
- Sungjin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Sung Il Kang
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Sohyun Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae Hwang Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Chang CC, Lan YT, Jiang JK, Chang SC, Yang SH, Lin CC, Lin HH, Wang HS, Chen WS, Lin TC, Lin JK. Risk factors for delayed perineal wound healing and its impact on prolonged hospital stay after abdominoperineal resection. World J Surg Oncol 2019; 17:226. [PMID: 31864365 DOI: 10.1186/s12957-019-1768-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/06/2019] [Indexed: 11/23/2022] Open
Abstract
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.
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Uğur M, Oruç C, Yıldız İ, Koca YS, Daban U. The role of co-administration of damage control surgery and vacuum-assisted closure in the treatment of perineal wounds. Turk J Surg 2018; 34:229-230. [PMID: 30302426 DOI: 10.5152/turkjsurg.2017.3257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 10/04/2015] [Indexed: 11/22/2022]
Abstract
Perineal wounds caused by high-kinetic-energy shotgun blasts have a high mortality risk because they are often accompanied by injuries of the anus, rectum, genitourinary system, and extremities. Mortality often results from hemorrhage in the early stage and from multiple organ failure caused by sepsis in the late stage. The primary step in the treatment of patients presenting with perineal wound and hemodynamic instability caused by severe hemorrhage is to control hemorrhage and contamination using damage control surgery. After achieving hemodynamic stability, vacuum-assisted closure can be used to reduce the risks of infection and sepsis. In this report, we present a case who had a perineal wound caused by a mine blast and was successfully treated by damage control surgery and vacuum-assisted closure.
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Affiliation(s)
- Mustafa Uğur
- Department of General Surgery, Mustafa Kemal University School of Medicine, Hatay, Turkey
| | - Cem Oruç
- Department of General Surgery, Mustafa Kemal University School of Medicine, Hatay, Turkey
| | - İhsan Yıldız
- Department of General Surgery, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Yavuz Savaş Koca
- Department of General Surgery, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Uğraş Daban
- Department of General Surgery, Mustafa Kemal University School of Medicine, Hatay, Turkey
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Bhingare PD, Shelke UR, Bang YA. A Case of Recto-Vesico-Cutaneous Fistula Following Perineal Injury by Wild Boar. J Clin Diagn Res 2016; 10:PD03-4. [PMID: 27437297 DOI: 10.7860/jcdr/2016/17947.7769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/05/2016] [Indexed: 11/24/2022]
Abstract
It is very uncommon for a boar to become aggressive in nature against human unless they are cornered. A wild boar attacked a 24-year-old male from behind in perineal region. At presentation, he had continuous dribbling of urine and fecal matter from perineal wound. On CT-scan, a well defined tract delineated by contrast was seen between postero-lateral aspect of bladder and anterior wall of rectum, and there was contrast extravasation through perineal wound. After resuscitation, fistula was repaired through abdominal approach, and perineal wound was debrided. Emergency physician should be aware of such cases as increasing deforestation and shifting of humans to sub-urban area, have resulted in increased incidences of wild boar attack. Prompt stabilization of patient, treatment of infection with proper antibiotics, prevention of tetanus and rabies infection and emergency surgical interventions are necessary to reduce morbidity and mortality from such trauma.
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Affiliation(s)
- Pravin D Bhingare
- Associate Professor, Department of General Surgery, Government Medical College , Nagpur, Maharashtra, India
| | - Umesh Ravikant Shelke
- Super-Speciality Medical Officer, Department of Urology, Seth GS Medical College & KEM Hospital , Mumbai, Maharashtra, India
| | - Yogesh A Bang
- Senior Resident, Department of Gastro-Intestinal Surgery, Asian Heart Institute , Hyderabad, India
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Au S, Moyes LH, Telfer JR, Anderson JH. Karydakis flap for post-proctectomy perineal sinus: A case series and review. Int J Surg Case Rep 2016; 23:157-9. [PMID: 27138449 DOI: 10.1016/j.ijscr.2016.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/19/2016] [Indexed: 12/02/2022] Open
Abstract
Persistent perineal sinus is a troublesome and common complication post-proctectomy. Treatment can be simple and ineffective or complex but relatively successful. Karydakis procedure is a treatment for pilonidal sinus and has never been reported to be used to treat persistent perineal sinus. Two cases, both suffered from Crohn’s disease and persistent perineal sinus, had complete healing with no short term recurrence after Karydakis procedure.
Introduction Persistent perineal sinus (PPS) may occur in up to 38% of patients undergoing proctectomy. The available therapeutic options range from simple but ineffective to relatively successful but complex. The Karydakis procedure is a straightforward day-case operation, commonly performed by general surgeons in the treatment of pilonidal disease, a not dissimilar pathology to PPS. This report is the first in the literature describing the use of Karydakis procedure in patients who developed PPS after proctectomy for Crohn’s disease. Presentation of case Two patients, both of whom suffered from Crohn’s disease and a PPS, underwent a Karydakis procedure as first-line treatment for PPS. Case 1 had a relatively superficial PPS while Case 2 had a deeper, more complex and longstanding PPS. Both patients had no post-operative complications and were discharged on the same day. They achieved complete healing in eight weeks and eight months respectively. The follow up range was 8–16 months. Discussion Various techniques, including complex myocutaneous flap reconstruction, have been described in the literature to treat PPS. In contrast to these complex techniques, Karydakis operation is a simple day case procedure that was successful in treating PPS in our patients. While there is robust data regarding low recurrence rates following a Karydakis flap for pilonidal disease, there is no existing data for the indication outlined in this report. Conclusion While it requires further assessment, the Karydakis operation has potential as a simple, safe and effective first-line treatment in selected patients with PPS while not precluding more complex operative options in the future.
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Fujino S, Miyoshi N, Ohue M, Noura S, Fujiwara Y, Yano M, Higashiyama M, Sakon M. Vacuum-assisted closure for open perineal wound after abdominoperineal resection. Int J Surg Case Rep 2015; 11:87-90. [PMID: 25942750 PMCID: PMC4446692 DOI: 10.1016/j.ijscr.2015.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/24/2015] [Accepted: 04/26/2015] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION In colorectal cancer surgery, surgical site infection (SSI) is a common complication, and especially, perineal wound complications after abdominoperineal resection (APR) remain to be serious clinical problems. Vacuum-assisted closure (VAC) therapy was first reported in another surgical field in 1997, and it is useful for treating complex wounds because it promotes granulation. VAC therapy has been recently used for open abdominal wounds. We introduced VAC for treating open perineal wound of APR and report the usefulness of it. PRESENTATION OF CASE We treated four patients. Firstly, in cases 1 and 2, we introduced VAC therapy to the management of SSI of the perineal wound after APR, and it was useful to control postoperative perineal wound infection. And also, in cases 3 and 4, we introduced VAC therapy to prevent perineal wound infection. Perineal wound infection did not happen. DISCUSSION A vertical rectus abdominis myocutaneous flap has been reported to decrease perineal wound complications including pelvic abscess and open perineal wound; however it results in significant operative blood loss, increased operative time, and additional surgical complications. In our cases, there were no complications relating to VAC therapy and it promoted rapid wound healing. Our results suggested that it is an effective treatment for APR in a high-risk case of an open perineal wound. CONCLUSION VAC therapy is a less invasive method and a useful treatment for open perineal wound of APR.
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Affiliation(s)
- Shiki Fujino
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Norikatsu Miyoshi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan.
| | - Masayuki Ohue
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Shingo Noura
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Masahiko Yano
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Masahiko Higashiyama
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
| | - Masato Sakon
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
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Abstract
Perineal wounds after abdominoperineal resection for rectal cancer are associated with impaired healing capacity, secondary to local defects and complications. To date, primary closure of the perineum and insertion of perineal drainage and irrigation are commonly used, but sometimes local morbidity and lack of wound healing occur. In this situation, wide exposure is required and the duration of hospital stay is prolonged. Various pedicle musculocutaneous flaps, such as gluteal and gracilis flaps, with local tamponade of the wound defect and reconstruction, may be an efficient way to manage non-healing perineal wounds and local reconstruction. This method significantly decreases the incidence of postoperative wound complications, shortens the healing time, and can be used selectively. Pedicle gracilis flaps are preferred, but require careful mobilization and perfect surgical skills. In this report, we summarize various techniques for the management of perineal wounds and their progression, and aim to obtain a better outcome for patients who are already suffering from artificial anus and the subsequent pain of perineal wounds.
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