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Thomas A, Ts S, Sleeba T, Antony A, George N. Median and medial umbilical ligament repositioning for prevention of pelviperineal complications following abdominoperineal resection-a case series and novel technique. Langenbecks Arch Surg 2024; 409:41. [PMID: 38228900 DOI: 10.1007/s00423-024-03225-y] [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: 08/06/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Pelviperineal complications after abdominoperineal resections are tough to treat. None of the available prophylactic methods has proven efficacy besides being technically challenging and expensive to perform. The present study aims to describe the technical details and short-term outcomes using mobilised umbilical ligaments to cover the pelvic inlet. TECHNIQUE After completing the rectal resection, the bladder with umbilical ligaments is mobilised anteriorly into the space of Retzius until the free edge can reach the sacral midline. Hitching stitches are taken to fix the umbilical ligaments into the new position. Seven consecutive patients had the umbilical ligament flap used for pelvic inlet closure. RESULTS Cross-sectional imaging on day 30 demonstrated the viable flap in all patients, and the small bowel descent was prevented. None of the seven patients had small bowel obstruction till day 90 after the operation. No patient required re-catheterisation, experienced major complications or wound infections that would necessitate re-intervention. CONCLUSION Using mobilised umbilical ligaments hitched to the pelvic inlet is a technically safe and feasible procedure to prevent pelviperineal complications after APR.
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Affiliation(s)
- Anand Thomas
- Department of Surgical Oncology, Rajagiri Cancer Centre, Rajagiri Hospital, Aluva, Kochi, Kerala, 683112, India.
| | - Subi Ts
- Department of Surgical Oncology, Rajagiri Cancer Centre, Rajagiri Hospital, Aluva, Kochi, Kerala, 683112, India
| | - Teena Sleeba
- Department of Radiodiagnosis, Rajagiri Hospital, Kochi, Kerala, India
| | - Abhijith Antony
- Department of Surgical Oncology, Rajagiri Cancer Centre, Rajagiri Hospital, Aluva, Kochi, Kerala, 683112, India
| | - Naveen George
- Department of Surgical Oncology, Rajagiri Cancer Centre, Rajagiri Hospital, Aluva, Kochi, Kerala, 683112, India
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Adanna Okeahialam N, Thakar R, Sultan AH. The clinical progression and wound healing rate of dehisced perineal tears healing by secondary intention: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 2022; 274:191-196. [PMID: 35667174 DOI: 10.1016/j.ejogrb.2022.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/04/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To establish the clinical progression of dehisced perineal wounds healing by secondary intention and to investigate the incidence and factors associated with delayed healing. METHODS Secondary analysis of women with perineal wound dehiscence recruited into the PERINEAL study between August 2020- August 2021 (NCT04480684). Three-dimensional wound measurements were taken with the Silhouette® camera. Significant bacterial colonisation was diagnosed using the MolecuLight i:X camera. As it is agreed that acute wounds should heal sufficiently within four weeks, diagnosis of delayed wound healing was made if a wound took longer than four weeks to heal. A wound was deemed to have healed if there was complete wound closure, with no evidence of granulation tissue or signs of infection on clinical examination. RESULTS 55 women with perineal wound dehiscence participated. Wounds took an average of 3 weeks to heal (range 1-16) and 38 (69.1%) wounds healed in ≤ 4 weeks from the first clinical review. 17 (30.9%) wounds had significant bacterial colonisation, identified on bacterial fluorescence imaging. Women with a wound area of < 1.60 cm2 or wound perimeter of < 5.57 cm had a 70% probability of wound healing in ≤ 4 weeks. 47.1% of wounds with significant bacteria colonisation healed within 4 weeks, in comparison to 78.9% of wounds not colonised (p = 0.03). 25.0 % (n = 2) of wounds with OASI healed within 4 weeks, in comparison to 76.5% (n = 36) of wounds with no OASI (p = 0.02). Bacterial fluorescence (OR 0.21 (0.05-0.87)) and OASIs (OR 0.09 (0.01-0.66)) were independent risk factors associated with delayed wound healing. The model including wound area, fluorescence and OASIs had the greatest AUC (0.81, 95% CI 0.67-0.94) indicating the best predictive model. CONCLUSIONS This is the first study to describe healing outcomes of dehisced perineal wounds and factors associated with delayed healing. The study findings will help clinicians counsel women effectively and tailor follow-up care at the first assessment, based on individual risk factors.
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Affiliation(s)
| | - Ranee Thakar
- Consultant Obstetrician and Urogynaecologist, Croydon University Hospital. Honorary Senior Lecturer, St George's University of London, UK.
| | - Abdul H Sultan
- Consultant Obstetrician and Urogynaecologist, Croydon University Hospital. Honorary Reader, St. George's University of London, UK.
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Kasai S, Kagawa H, Shiomi A, Hino H, Manabe S, Yamaoka Y, Kato S, Hanaoka M, Kinugasa Y. Advantages of robotic abdominoperineal resection compared with laparoscopic surgery: a single-center retrospective study. Surg Today 2021; 52:643-651. [PMID: 34417866 DOI: 10.1007/s00595-021-02359-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/12/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of this study was to compare the operative outcomes between robotic and laparoscopic abdominoperineal resection. METHODS This retrospective cohort study was conducted from April 2010 to March 2020. Patients with rectal cancer who underwent robotic or laparoscopic abdominoperineal resection without lateral lymph node dissection were enrolled. The perioperative and oncological outcomes were compared. RESULTS We evaluated 33 and 20 patients in the robotic and laparoscopic groups, respectively. The median operative time and blood loss were comparable between the two groups. No significant differences in the overall complication rates were noted, whereas the rates of urinary dysfunction (3% vs. 26%, p = 0.02) and perineal wound infection (9% vs. 35%, p = 0.03) in the robotic group were significantly lower in comparison to the laparoscopic group. The median postoperative hospital stay was significantly shorter in the robotic group (8 days vs. 11 days, p < 0.01). The positive resection margin rates were comparable between the two groups. CONCLUSION Robotic abdominoperineal resection demonstrated better short-term outcomes than laparoscopic surgery, suggesting that it could be a useful approach.
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Affiliation(s)
- Shunsuke Kasai
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.,Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroyasu Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hitoshi Hino
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Shoichi Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yusuke Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Shunichiro Kato
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Marie Hanaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.,Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Yusuke Kinugasa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.,Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Okeahialam NA, Thakar R, Kleprlikova H, Taithongchai A, Sultan AH. Early re-suturing of dehisced obstetric perineal wounds: A 13-year experience. Eur J Obstet Gynecol Reprod Biol 2020; 254:69-73. [PMID: 32942078 DOI: 10.1016/j.ejogrb.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 07/24/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To describe post-operative outcomes following early re-suturing of obstetric perineal wound dehiscence. STUDY DESIGN This was a retrospective series of 72 women who underwent re- suturing of a dehisced perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 - December 2019). RESULTS Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing. Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain (23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 % of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation (5.9 %). Of the women who developed two complications, four developed skin dehiscence with granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal pain. All complications were managed conservatively in an outpatient setting or surgically under local anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14) without signs of infection. CONCLUSIONS This study demonstrates the positive outcomes of early re-suturing of perineal wound dehiscence with faster healing, reduced follow-up requirements and few major complications. It provides information to clinicians who are uncertain about the effects of early re-suturing of perineal wounds which can be used to help counsel mothers with wound dehiscence on their management options.
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Affiliation(s)
| | - R Thakar
- Croydon University Hospital, London UK; Honorary Senior Lecturer St George's University of London, UK
| | - H Kleprlikova
- Croydon University Hospital, London UK; Department of General Anthropology, Faculty of Humanities, Charles University in Prague, Czech Republic
| | | | - A H Sultan
- Croydon University Hospital, London UK; Honorary Reader St. George's University of London, UK.
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Imaizumi K, Nishizawa Y, Ikeda K, Tsukada Y, Sasaki T, Ito M. Extended pelvic resection for rectal and anal canal tumors is a significant risk factor for perineal wound infection: a retrospective cohort study. Surg Today 2018; 48:978-985. [PMID: 29858669 DOI: 10.1007/s00595-018-1680-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 01/19/2018] [Accepted: 05/21/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Perineal wound infection (PWI) rates are high after abdominoperineal resection (APR) and total pelvic exenteration (TPE). This study identified risk factors for PWI after surgery for anorectal tumors and examined the relationship between the surgical excision volume with the PWI degree. METHODS A retrospective review involving 135 patients who underwent surgical excision of anorectal tumors was performed. Superficial PWI included cellulitis and superficial dehiscence; deep PWI included major dehiscence, perineal abscess, and presacral abscess. The adjacent organ resection type was classified according to the dead space size formed by surgical excision. RESULTS Of the 135 patients, 119 underwent APR, and 16 underwent TPE. PWI occurred in 75 patients (superficial PWI, 44; deep PWI, 31). Adjacent organ resection was an independent risk factor for PWI. The cases with adjacent organ resection were classified into small-defect APR, large-defect APR, and TPE. Large-defect APR and TPE cases had significantly higher rates of deep PWI than APR cases without adjacent organ resection. CONCLUSIONS Adjacent organ resection involving the removal of one or more organs and that involving wide-range muscle resection are strong risk factors for deep PWI.
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Affiliation(s)
- Ken Imaizumi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Schiltz B, Buchs NC, Penna M, Scarpa CR, Liot E, Morel P, Ris F. Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: A review. World J Clin Oncol 2017; 8:249-254. [PMID: 28638794 PMCID: PMC5465014 DOI: 10.5306/wjco.v8.i3.249] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/12/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds. Such large wounds are prone to infection and perineal herniation, and their closure is a major concern to most surgeons. Different approaches to the perineal repair exist, varying from primary or mesh closure to myocutaneous flaps. Each technique has its own associated advantages and potential complications and the ideal approach is still debated. In the present study, we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure. Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction. In addition, the rate of perineal hernia is lower in early follow-up, while long-term hernia occurrence appears to be similar between the different techniques. Finally, it is an easy and quick reconstruction method. Although more expensive than primary closure, the cost associated with the use of a biological mesh is at least equal, if not less, than flap reconstruction.
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Nakamura T, Sato T, Hayakawa K, Takayama Y, Naito M, Yamanashi T, Tsutsui A, Miura H, Watanabe M. Risk factors for perineal wound infection after abdominoperineal resection of advanced lower rectal cancer. Ann Med Surg (Lond) 2017; 15:14-18. [PMID: 28217301 PMCID: PMC5302139 DOI: 10.1016/j.amsu.2017.01.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 09/21/2016] [Revised: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Abdominoperineal resection (APR) of advanced lower rectal cancer carries a high incidence of perineal wound infection. The aim of this study was to retrospectively evaluate risk factors for perineal wound infection after APR. METHODS The study group comprised 154 patients who underwent APR for advanced lower rectal cancer in our department from January 1990 through December 2012. The following 15 variables were studied as potential risk factors for perineal wound infection: sex, age, body-mass index, American Society of Anesthesiologists score, diabetes mellitus, preoperative albumin level, preoperative hemoglobin level, neoadjuvant chemoradiotherapy(NCRT), surgical procedure (open surgery vs. laparoscopic surgery), operation time, bleeding volume, intraoperative transfusion, tumor diameter, invasion depth, and histopathological stage. RESULTS Among the 154 patients, 30 (19%) had perineal wound infection. Univariate analysis showed that a hemoglobin level of ≤11 g/dL (p = 0.001) and NCRT (p = 0.001) were significantly related to perineal wound infection. On multivariate analysis including the preoperative albumin level (≤3.5 g/dL) in addition to the above 2 variables, neoadjuvant chemoradiotherapy (NCRT) was the only independent risk factor for perineal wound infection. Perineal wound infection developed in 31% of patients who received NCRT, as compared with 10% of patients who did not receive NCRT. The relative risk of perineal infection in the former group was 4.092 as compared with the latter group (p = 0.0002). CONCLUSIONS NCRT is a risk factor for perineal wound infection after APR in patients with advanced lower rectal cancer.
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Affiliation(s)
| | - Takeo Sato
- Department of Surgery, Kitasato University School of Medicine, Japan
| | - Kazushige Hayakawa
- Department of Radiology and Radiation Oncology, Kitasato University Hospital, Japan
| | - Yoko Takayama
- Department of Infection Control and Infectious Diseases Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Japan
| | - Masanori Naito
- Department of Surgery, Kitasato University School of Medicine, Japan
| | | | - Atsuko Tsutsui
- Department of Surgery, Kitasato University School of Medicine, Japan
| | - Hirohisa Miura
- Department of Surgery, Kitasato University School of Medicine, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University School of Medicine, Japan
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Walma MS, Burbach JPM, Verheijen PM, Pronk A, van Grevenstein WMU. Vacuum-assisted closure therapy for infected perineal wounds after abdominoperineal resection. A retrospective cohort study. Int J Surg 2015; 26:18-24. [PMID: 26718610 DOI: 10.1016/j.ijsu.2015.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [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: 09/04/2015] [Revised: 11/18/2015] [Accepted: 12/01/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Perineal wound complications are a main problem after abdominoperineal resection (APR). There is little evidence concerning perineal wound management. This study describes and evaluates the role of vacuum-assisted closure (VAC) therapy in wound management strategies of perineal wound infections after APR. METHODS Patients undergoing APR for malignant disease between January 2007 and January 2013 were identified retrospectively. Data regarding occurrence and management of perineal wound complications were collected. Perineal wound infections were classified into minor or major complications and time to wound healing was measured. Time to wound healing was compared between patients receiving routine care or with additional VAC therapy. RESULTS Of 171 included patients, 76 (44.4%) had minor and 36 (21.1%) major perineal wound infections. Management of major infected perineal wounds consisted of drainage (n = 16), debridement (n = 4), drainage combined with debridement (n = 4), VAC therapy alone (n = 5), or VAC therapy combined with other treatments (n = 7). Median duration of perineal wound healing in major infected wounds was 141 days (range 17-739). Median time to wound healing was not different in patients treated with (172 days, range 23-368) or without VAC therapy (131 days, range 17-739). DISCUSSION AND CONCLUSION In this study, VAC therapy did not shorten time to wound healing. However, prospective studies are required to investigate the role of VAC therapy in management of infected perineal wounds after APR. Up to then, wound management will remain to be based on clinical perception and 'gut-feeling'.
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Affiliation(s)
- M S Walma
- Department of Surgery, University Medical Centre, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - J P M Burbach
- Department of Surgery, University Medical Centre, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - A Pronk
- Department of Surgery, Diakonessenhuis, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - W M U van Grevenstein
- Department of Surgery, University Medical Centre, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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