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Calpin GG, Davey MG, Maguire B, Morarasu S, Donlon NE, Cahill KC, Larkin JO. Optimal approaches to flap reconstruction following abdominoperineal resection: A systematic review. Surgeon 2025; 23:155-161. [PMID: 39947998 DOI: 10.1016/j.surge.2025.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 10/29/2024] [Accepted: 01/31/2025] [Indexed: 05/20/2025]
Abstract
PURPOSE Abdominoperineal resection (APR) frequently results in a large volume perineal defect. Flap reconstruction is commonly undertaken to reduce the rate of perineal complications associated with primary closure. Several techniques can be employed including vertical rectus abdominis (VRAM), gluteal myocutaneous and gluteal fasciocutaneous flaps. We aimed to compare perineal complication rates between flap reconstruction techniques. METHODS A systematic review was conducted following PRISMA guidelines. Databases were searched for studies reporting perineal complications following flap reconstruction post-APR. Demographic data for each study was extracted along with overall perineal complication rate, infectious complication, flap necrosis, dehiscence, and failure. RESULTS In total, 31 studies with 764 patients were included. Rectal cancer was the underlying pathology in 71.3 % (545/764), anal cancer in 23.6 % (180/764), and other in 5.1 % (39/764). VRAM flap reconstruction was performed in 57.2 % of cases (437/764), gluteal myocutaneous in 25.1 % (192/764), and gluteal fasciocutaneous in 17.7 % (135/764). Infection, dehiscence, haematoma, seroma, and flap failure rates were comparable among the different groups. Flap necrosis occurred in 4.6 % of the VRAM group and was significantly higher than in the other groups (P = 0.028). The rate of reoperation (9.1 %) was also significantly higher in the VRAM group (P = 0.038). Perineal hernia formation occurred in 14.9 % of the gluteal fasciocutaneous group and was significantly higher than in the other groups (P < 0.001). CONCLUSION Flap necrosis and reoperation rates are higher after VRAM flap reconstruction. Perineal hernia rates are higher in gluteal fasciocutaneous flap reconstruction. A randomised controlled trial is needed to further investigate the outcomes of flap reconstruction.
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Affiliation(s)
- Gavin G Calpin
- Department of Colorectal Surgery, St. James's Hospital, Dublin, 8, Ireland; Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland.
| | - Matthew G Davey
- Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland
| | - Barry Maguire
- Department of Colorectal Surgery, St. James's Hospital, Dublin, 8, Ireland; Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland
| | - Stefan Morarasu
- Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland
| | - Noel E Donlon
- Department of Colorectal Surgery, St. James's Hospital, Dublin, 8, Ireland; Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland
| | - Kevin C Cahill
- Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland; Department of Plastic Surgery, Beaumont Hospital, Dublin, 9, Ireland
| | - John O Larkin
- Department of Colorectal Surgery, St. James's Hospital, Dublin, 8, Ireland; Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin, 2, Ireland
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Zhu Z, Jiang D, Jiang Y, Quan J, Zhang M, Pei W, Bi J, Feng Q, Zhou H, Wang Z, Zheng Z, Liu Q, Zhao Z, Liang J. Dentate line invasion is a risk factor for locoregional recurrence and distant metastasis following abdominoperineal resection in rectal cancer: a single-centre retrospective cohort study based on 1854 cases. BMC Cancer 2025; 25:574. [PMID: 40159477 PMCID: PMC11956476 DOI: 10.1186/s12885-025-14001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 03/24/2025] [Indexed: 04/02/2025] Open
Abstract
BACKGROUND In the context of surgical treatment for rectal cancer, the dentate line is acknowledged as a critical anatomical landmark. However, the prognostic implications of dentate line invasion (DLI) remain elusive and warrant further investigation. This study aims to evaluate and compare the outcomes of patients with rectal cancer who underwent abdominoperineal resection (APR), distinguishing between those with and without DLI. MATERIALS AND METHODS Between January 2006 and December 2017, this study enrolled 1854 patients with rectal cancer who underwent APR. The cohort was divided into two groups, namely the DLI group (n = 340) and the non-DLI group (n = 1514). The primary endpoints were distant relapse-free survival (DRFS) and local recurrence-free survival (LRFS). Univariate and multivariate analyses were conducted to assess the impact of DLI on DRFS, LRFS, overall survival (OS), and disease-free survival (DFS). RESULTS The median follow-up duration for the patients was 92.9 months, with a 5-year OS rate of 92.0% for the entire cohort. Compared to the non-DLI group, patients in the DLI group showed significantly poorer outcomes, with 5-year DRFS at 57.4% vs. 73.9% (P < 0.001), DFS at 51.2% vs. 70.7% (P < 0.001), and LRFS at 71.7% vs. 88.5% (P = 0.018). OS was the only metric that showed no significant difference(89.0% vs. 92.6%, P = 0.064). Multivariate analysis demonstrated that DLI negatively impacted DRFS (hazard ratio HR 1.319, P = 0.029), LRFS (HR 2.059, P < 0.001), and DFS (HR 1.563, P < 0.001) as an independent prognostic factor. Furthermore, distant metastasis occurred more frequently in the DLI group (30.0% vs. 23.1%, P = 0.002), along with a higher rate of locoregional recurrence. (16.8% vs. 8.3%, P < 0.001). CONCLUSIONS DLI correlates with a heightened likelihood of locoregional recurrence and distant metastasis among rectal cancer patients treated with APR. This association underscores the significance of DLI as a crucial prognostic factor that should be considered when developing clinical management strategies.
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Affiliation(s)
- Zixing Zhu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Dedi Jiang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Yujuan Jiang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Jichuan Quan
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Mingguang Zhang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Wei Pei
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Jianjun Bi
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Qiang Feng
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Haitao Zhou
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Zheng Wang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Zhaoxu Zheng
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Qian Liu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Zhixun Zhao
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China.
| | - Jianwei Liang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan South Lane, Chaoyang District, Beijing, 100021, China.
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Kulle CB, Bozkurt HA, Tuncak M, Bayraktar A, Özgür I, Bulut MT, Keskin M. Pelvic inlet closure with bladder peritoneal flap reduces postoperative ileus after abdominoperineal resection. Tech Coloproctol 2024; 29:32. [PMID: 39704852 DOI: 10.1007/s10151-024-03059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 11/06/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND Abdominoperineal resection (APR) is the standard treatment for locally advanced distal rectal cancer (LADRC) following neoadjuvant treatment when sphincter-preserving procedures are inapplicable. However, complications such as perineal site infection, perineal hernia and postoperative ileus remain ongoing challenges. We aimed to compare the rate of postoperative ileus due to pelvic incarceration in APR patients with/without pelvic inlet closure. METHODS LADRC patients, who underwent APR with/without pelvic inlet closure between January 2016 and September 2022 at a comprehensive cancer center were analyzed retrospectively. After laparoscopic APR, the pelvic inlet was closed with a bladder peritoneal flap. A U-shaped peritoneal flap, up to approximately 15 × 20 cm in size, was peeled off from the dome of the bladder with its base at the posterosuperior part of the bladder. RESULTS Of the 80 patients included in the analysis, 27 (34%) underwent laparoscopic APR with pelvic inlet closure and 53 (66%) had no pelvic inlet closure. There was no significant difference in age, mean body mass index and American Society of Anesthesiologists score among both groups. Patients with a pelvic inlet closure had a significantly lower postoperative ileus rate because of incarceration [0 vs. 17%, n = 9/53; (P = 0.03)] and a shorter hospital stay [6.74 ± 4.21 vs. 9.00 ± 5.99 days; P = 0.03]. The rate of perineal surgical site infection (SSI) [5/27 (18.5%) vs. 14/53 (26.4%); P = 0.61) was lower in the laparoscopic APR with pelvic inlet closure group, but this was not significant. CONCLUSION Pelvic inlet closure using a bladder peritoneal flap following APR is a safe and feasible procedure associated with reduced postoperative ileus due to pelvic incarceration rates, emergent surgical interventions due to pelvic incarceration and shorter hospital stay.
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Affiliation(s)
- C B Kulle
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey.
| | - H A Bozkurt
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - M Tuncak
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - A Bayraktar
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - I Özgür
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - M T Bulut
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - M Keskin
- Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
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Polovinkin VV, Doronin NV, Shiraliev RMA, Petrovsky AN. Reconstruction of the pelvic floor and perineal wound after extralevator abdominoperineal resection of the rectum. Tech Coloproctol 2024; 29:21. [PMID: 39699774 DOI: 10.1007/s10151-024-03031-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 10/13/2024] [Indexed: 12/20/2024]
Abstract
This article presents an innovative technique for perineal wound reconstruction following extralevator abdominoperineal excision (ELAPE) in rectal cancer surgery. The authors trace the evolution of surgical methods for rectal cancer treatment, from W.E. Miles' abdominoperineal resection (APR) to T. Holm's ELAPE technique introduced in 2007. The proposed metod's primary advantage lies in its ability to completely fill the extensive deep and superficial perineal wound defect by moving two flaps from both sides of the wound and overlapping them. This approach potentially reduces postoperative complications and improves patients' quality of life following ELAPE. The authors describe the procedure in detail, including specific measurements and angles for flap creation. They also present a case study of a 52-year-old female patient with lower rectal ampulla cancer, demonstrating the practical application of this technique. This innovative reconstruction method addresses the current lack of consensus on perineal wound plastic surgery techniques following ELAPE and offers a promising solution to reduce postoperative morbidity in rectal cancer patients undergoing this procedure.
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Affiliation(s)
- V V Polovinkin
- Research Institute-Regional Clinical Hospital No. 1 Named After. Prof. S.V. Ochapovsky" (Ministry of Healthcare of the Krasnodar Region), Krasnodar, Russia
- Kuban State Medical University (Ministry of Healthcare of the Russian Federation), Krasnodar, Russia
| | - N V Doronin
- Clinical Oncology Dispensary No.1 (Ministry of Healthcare of Krasnodar Region), Krasnodar, Russia
| | - R M-A Shiraliev
- Clinical Oncology Dispensary No.1 (Ministry of Healthcare of Krasnodar Region), Krasnodar, Russia
| | - A N Petrovsky
- Research Institute-Regional Clinical Hospital No. 1 Named After. Prof. S.V. Ochapovsky" (Ministry of Healthcare of the Krasnodar Region), Krasnodar, Russia.
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Coco C, Rizzo G, Amodio LE, Pafundi DP, Marzi F, Tondolo V. Current Management of Locally Recurrent Rectal Cancer. Cancers (Basel) 2024; 16:3906. [PMID: 39682094 DOI: 10.3390/cancers16233906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2024] [Revised: 11/13/2024] [Accepted: 11/20/2024] [Indexed: 12/18/2024] Open
Abstract
Locally recurrent rectal cancer (LRRC), which occurs in 6-12% of patients previously treated with surgery, with or without pre-operative chemoradiation therapy, represents a complex and heterogeneous disease profoundly affecting the patient's quality of life (QoL) and long-term survival. Its management usually requires a multidisciplinary approach, to evaluate the several aspects of a LRRC, such as resectability or the best approach to reduce symptoms. Surgical treatment is more complex and usually needs high-volume centers to obtain a higher rate of radical (R0) resections and to reduce the rate of postoperative complications. Multiple factors related to the patient, to the primary tumor, and to the surgery for the primary tumor contribute to the development of local recurrence. Accurate pre-treatment staging of the recurrence is essential, and several classification systems are currently used for this purpose. Achieving an R0 resection through radical surgery remains the most critical factor for a favorable oncologic outcome, although both chemotherapy and radiotherapy play a significant role in facilitating this goal. If a R0 resection of a LRRC is not feasible, palliative treatment is mandatory to reduce the LRRC-related symptoms, especially pain, minimizing the effect of the recurrence on the QoL of the patients. The aim of this manuscript is to provide a comprehensive narrative review of the literature regarding the management of LRRC.
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Affiliation(s)
- Claudio Coco
- UOC Chirurgia Generale 2, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Gianluca Rizzo
- UOC Chirurgia Digestiva e del Colon-Retto, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy
| | - Luca Emanuele Amodio
- UOC Chirurgia Digestiva e del Colon-Retto, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy
| | - Donato Paolo Pafundi
- UOC Chirurgia Generale 2, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Federica Marzi
- UOC Chirurgia Digestiva e del Colon-Retto, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy
| | - Vincenzo Tondolo
- UOC Chirurgia Digestiva e del Colon-Retto, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy
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Geng Y, Liu J, Yin X, Zhao R, Zhu L. Reconstruction for extensive sacrococcygeal defects in complex tumor patients with personalized customized gluteus maximus myocutaneous flaps. J Tissue Viability 2024; 33:883-888. [PMID: 39242280 DOI: 10.1016/j.jtv.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 08/17/2024] [Accepted: 08/23/2024] [Indexed: 09/09/2024]
Abstract
AIM To evaluate the clinical effects of personalized customized gluteus maximus myocutaneous flaps (GMMF) for reconstruction of extensive sacrococcygeal soft tissue defects in complex tumor patients. METHODS A retrospective chart review was conducted on 8 patients who underwent personalized customized GMMF reconstruction for large sacrococcygeal defect from December 2021 to August 2023. The personalized customized GMMF were designed based on the variations of tissue defect in location, shape and volume of different dead spaces. The principle of the personalized GMMF is to ensure that the rotation point of the flap can reach the farthest end of the defect. Patient demographics, operative characteristics, and perioperative risk factors were analyzed. Clinical outcomes were assessed, focusing on complications such as flap necrosis, wound dehiscence, infection, seroma, and hematoma. RESULTS Six patients with rectal cancer and two with sacral tumors underwent personalized customized GMMF reconstruction for extensive sacrococcygeal defects. The average volume of the wound cavity was 104 mL, with a mean vertical depth was 10.8 cm. Six patients had low serum albumin (<35 g/L). After a mean follow-up of 15.5 months, no major complications occurred, except for one seroma that resolved within 2 weeks. CONCLUSION The personalized customized GMMF described in this study is an effective method for reconstructing large sacrococcygeal wounds with significant depth in complex tumor patients. It allows for greater rotation of the muscle flap into the sacrococcygeal wound defect and provides adequate blood supply by utilizing the bulk of muscle tissue to obliterate dead space.
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Affiliation(s)
- Yingnan Geng
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China
| | - Jinyue Liu
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China
| | - Xiaolin Yin
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China
| | - Rongxin Zhao
- Department of Dermatology, Pudong New Area People's Hospital, 490 Chuanhuan South Road, Pudong New Area, Shanghai, China
| | - Lie Zhu
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China.
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Zhang X, Li X, Qin Q, Wang Y. Application of modified extralevator abdominoperineal excision for low rectal cancer resection. Surg Endosc 2024; 38:6177-6183. [PMID: 39266762 DOI: 10.1007/s00464-024-11246-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 08/30/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND Laparoscopic ELAPE surgery has been carried out in our center for a long time, and some modifications have been made in clinical practice. In this study, we compared conventional ELAPE operation with modified ELAPE operation to investigate the efficacy and safety of modified ELAPE operation. METHODS We retrospectively analyzed the data from 339 patients with low rectal cancer undergoing abdominoperineal resection from 2017 to 2021 in the Department of General Surgery, Qilu Hospital of Shandong University. Patients were classified into modified ELAPE groups (199 patients) and conventional ELAPE groups (140 patients). Total operation time, reconstruction time, postoperative hospital stay, total cost, intraoperative data, postoperative short-term and long-term complications and tumor recurrence were compared. RESULTS The baseline characteristics were comparable between the two groups. Total operation time was less with modified ELAPE group compared to conventional ELAPE group (190.6 ± 33.1 min vs 230.1 ± 51.6 min, P = 0.022). Pelvic floor reconstruction time was also less with modified ELAPE group compared to conventional ELAPE group (4.3 ± 1.2 min vs 11.9 ± 1.7 min, P = 0.004). Positive CRM was observed in 11 and 9 patients in modified ELAPE groups and conventional ELAPE groups (P = 0.744). IOP occurred in 12 and 7 patients in modified ELAPE group and conventional ELAPE group (P = 0.701). Total cost was also less with modified ELAPE group compared to conventional ELAPE group (9004 ± 1146 USD vs 10,336 ± 2047 USD, P = 0.031). The incidence of parastomal hernia was less with modified ELAPE group compared to conventional ELAPE group (7/199 vs 22/140, P < 0.001). Three-year follow-up data did not show any difference in overall survival rate or local occurrence between the two groups. CONCLUSION Modified ELAPE surgery is technically safe and feasible, and oncologically comparable to that of conventional ELAPE surgery, which can be considered for popularization and application.
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Affiliation(s)
- Xiang Zhang
- Department of Colorectal Surgery, Qilu Hospital, Shandong University, Jinan, 250012, Shandong Province, China
| | - Xin Li
- Department of General Surgery, Huantai Branch of Qilu Hospital of Shandong University, Zibo, Shandong, China
| | - Qingdi Qin
- Department of Colorectal Surgery, Qilu Hospital, Shandong University, Jinan, 250012, Shandong Province, China
| | - Yanlei Wang
- Department of Colorectal Surgery, Qilu Hospital, Shandong University, Jinan, 250012, Shandong Province, China.
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Valadão M, Riechelmann RP, Silva JACE, Mali J, Azevedo B, Aguiar S, Araújo R, Feitoza M, Coelho E, Rosa AA, Jay N, Braun AC, Pinheiro R, Salvador H. Brazilian Society of Surgical Oncology: Guidelines for the management of anal canal cancer. J Surg Oncol 2024; 130:810-829. [PMID: 37021640 DOI: 10.1002/jso.27269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Anal canal squamous cell carcinoma (SCC) is a relatively uncommon neoplasia, and it is mostly a local-regional cancer, of low metastatic potential (only 15%), resulting in cure in most cases treated with definitive chemoradiation. On the other hand, its incidence has been steadily increasing over the last decades, which makes it an important public health problem. In an effort to provide surgeons and oncologists who treat patients with anal cancer with the most updated information based on the best scientific evidence, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guideline for the management of anal canal SCC, focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the management of anal canal squamous cell carcinoma (SCC) based on current scientific evidence. METHODS Between October 2022 and January 2023, 14 experts met to develop the guidelines for the management of anal canal cancer. A total of 30 relevant topics were distributed among the participants. The methodological quality of a final list with 121 sources was evaluated, all the evidence was examined and revised, and the management guidelines were formulated by the 14-expert committee. To reach a final consensus, all the topics were reviewed in a meeting that was attended by all the experts. RESULTS The proposed guidelines contained 30 topics considered to be highly relevant in the management of anal canal cancer, covering subjects related to screening recommendations, preventive measures, tests required for diagnosing and staging, treatment strategies, response assessment after chemoradiotherapy, surgical technique-related aspects, and follow-up recommendations. In addition, screening and response assessment algorithms, and a checklist were proposed to summarize the important information and offer an updated tool to assist surgeons and oncologists who treat anal canal cancer and in providing the best care to their patients. CONCLUSION These guidelines summarize recommendations based on the most current scientific evidence on relevant aspects of anal canal cancer management and are a practical guide to help surgeons and oncologists who treat anal canal cancer make the best therapeutic decisions.
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Affiliation(s)
- Marcus Valadão
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Jorge Mali
- Department of Surgery, Hospital do Câncer de Londrina, Londrina, Brazil
| | - Bruno Azevedo
- Department of Surgical Oncology, Grupo Oncoclínicas, Curitiba, Brazil
| | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer, CenterSão Paulo, Brazil
| | - Rodrigo Araújo
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Mario Feitoza
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - Eid Coelho
- Department of Surgery, Hospital São Marcos, Teresina, Brazil
| | - Arthur Accioly Rosa
- Department of Radiation Oncology, Oncoclinicas Salvador-Hospital Santa Izabel, Salvador, Brazil
| | - Naomi Jay
- San Francisco School of Medicine, University of California, San Francisco, California, USA
| | | | - Rodrigo Pinheiro
- Department of Surgical Oncology, Hospital de Base do Distrito Federal, Brasilia, Brazil
| | - Héber Salvador
- Department of Surgical Oncology, AC Camargo Cancer, CenterSão Paulo, Brazil
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Park YY, Kim NK. Tailoring rectal cancer surgery: Surgical approaches and anatomical insights during deep pelvic dissection for optimal outcomes in low-lying rectal cancer. Ann Gastroenterol Surg 2024; 8:761-773. [PMID: 39229569 PMCID: PMC11368511 DOI: 10.1002/ags3.12824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/03/2024] [Accepted: 05/09/2024] [Indexed: 09/05/2024] Open
Abstract
This review article explores advanced surgical approaches and anatomical insights for tailoring rectal cancer surgery, particularly focusing on low-lying rectal cancer. With the evolution of imaging technologies, precise preoperative planning has become possible, enhancing the visualization of anatomy surrounding the rectum and enabling more accurate assessments of circumferential resection margin (CRM) involvement. The article emphasizes the dynamic nature of rectal cancer treatment, advocating for individualized surgical planning based on comprehensive preoperative imaging and intraoperative assessment. This approach aims to optimize patient care by integrating recent advancements and anatomical insights into clinical practice for the management of low-lying rectal cancer. Particularly, the article discusses the importance of customizing the excision of Denonvilliers' fascia (DVF) based on tumor characteristics for optimal oncologic and functional outcomes, especially for anteriorly located tumors. It highlights the need for precise dissection techniques to ensure a negative CRM while preserving critical anatomical structures. Additionally, the review addresses the surgical management of tumors at the anorectal ring and introduces the Gate Approach for deep anterolateral pelvic dissection. Special attention is given to tumors impacting the membranous and prostate urethra, emphasizing tailored surgical approaches to balance complete tumor resection with the preservation of urogenital functions.
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Affiliation(s)
- Youn Young Park
- Department of Surgery, Kyung Hee University Hospital at GangdongKyung Hee University College of MedicineSeoulKorea
| | - Nam Kyu Kim
- Colorectal Division, Department of Surgery, Yongin Severance HospitalYonsei University College of MedicineGyeonggi‐doKorea
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Khattak MA, Khan AN, Jafferi S, Iqbal Y, Abdulrasheed H, McArthur D. Perineal Wound Healing Following Abdominoperineal Resection of the Rectum. Cureus 2024; 16:e66318. [PMID: 39238678 PMCID: PMC11377100 DOI: 10.7759/cureus.66318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVE This study aimed to investigate perineal wound healing rates following abdominoperineal resection (APR) or extralevator abdominoperineal excision (ELAPE) for rectal cancer, with a focus on identifying associated risk factors and outcomes. METHODOLOGY A retrospective analysis was conducted on patients undergoing APR or ELAPE for rectal cancer in a tertiary centre between 2013 and 2020. Data on demographics, comorbidities, surgical techniques, and perineal wound outcomes were collected and analyzed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 27.0, Armonk, NY). Statistical significance was set at p<0.05. RESULTS A total of 87 patients were included, with a mean age of 64 years and the majority being male (66.7%). Neoadjuvant radiotherapy was administered in 87.4% of cases. Perineal wound complications were documented in 52 cases (59.8%), with major complications observed in 11 cases (12.6%). Healing within six months was achieved in 48 patients (55.2%), while 39 patients (44.8%) developed chronic perineal wounds. Logistic regression analysis revealed omentoplasty as a significant predictor of perineal wound healing rate showing a significant negative association (p=0.0289). CONCLUSION Perineal wound healing rates following APR or ELAPE varied. While most patients achieved complete healing, chronic perineal wounds presented challenges. Omentoplasty was associated with lower odds of healing, suggesting the need for further investigation into its role. These findings underscore the importance of patient counselling and multidisciplinary management strategies to optimize outcomes in rectal cancer surgery.
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Affiliation(s)
- Muhammad Ali Khattak
- Urology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | | | - Salman Jafferi
- General Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - Yasir Iqbal
- Acute and General Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Habeeb Abdulrasheed
- Urology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - David McArthur
- General Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
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Matsuda T, Takemasa I, Endo H, Mori S, Hasegawa S, Hida K, Tokunaga T, Tanaka K, Mukai T, Watanabe J, Kawamura J, Kimura K, Kakeji Y, Watanabe M, Yamamoto S, Naitoh T. Local Recurrence of Rectal Cancer After Transanal Total Mesorectal Excision and Risk Factors: A Nationwide Multicenter Cohort Study in Japan. ANNALS OF SURGERY OPEN 2024; 5:e369. [PMID: 38883940 PMCID: PMC11175902 DOI: 10.1097/as9.0000000000000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/20/2023] [Indexed: 06/18/2024] Open
Abstract
Objective To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR). Background A high LR rate with a multifocal pattern early after TaTME has been reported in Norway and the Netherlands, causing controversy over the oncological safety of this technique. Methods Twenty-six member institutions of the Japan Society of Laparoscopic Colorectal Surgery participated in this retrospective cohort study. A total of 706 patients with primary rectal cancer who underwent TaTME between January 2012 and December 2019 were included for analysis. The primary endpoint was the cumulative 3-year LR rate. Results A total of 253 patients had clinical stage III disease (35.8%) and 91 (12.9%) had stage IV. Intersphincteric resection was performed in 318 patients (45.0%) and abdominoperineal resection in 193 (27.3%). There was 1 urethral injury (0.1%). A positive resection margin (R1) was seen in 42 patients (5.9%). Median follow-up was 3.42 years, and the 2- and 3-year cumulative LR rates were 4.95% (95% confidence interval: 3.50-6.75) and 6.82% (95% confidence interval: 5.08-8.89), respectively. A multifocal pattern was observed in 14 (25%) of 56 patients with LR. Tumor height from the anal verge, pathological T4 disease, pathological stage III/IV, positive perineural invasion, and R1 resection were significant risk factors for LR in multivariable analysis. Conclusions In this selected cohort in which intersphincteric resection or abdominoperineal resection was performed in more than half of cases, oncological outcomes were acceptable during a median follow-up of more than 3 years.
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Affiliation(s)
- Takeru Matsuda
- From the Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science Sapporo Medical University, Sapporo, Japan
| | - Hideki Endo
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical Sciences, Kagoshima, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuya Tokunaga
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Keitaro Tanaka
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Toshiki Mukai
- Gastroenterological Center, Department of Gastroenterological Surgery, the Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Jun Watanabe
- Department of Surgery, Gastroenterological Center Yokohama City University Medical Center, Yokohama, Japan
| | - Junichiro Kawamura
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Kei Kimura
- Division of Lower G.I., Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Yoshihiro Kakeji
- From the Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Seiichiro Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Takeshi Naitoh
- Department of Lower Gastrointestinal Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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12
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Choi J, Kim RY, Lee CR, Choi JY, Moon SH, Oh DY, Jun YJ. Reconstruction and Management Strategies for Pelvic Ablative Surgery. JOURNAL OF WOUND MANAGEMENT AND RESEARCH 2024; 20:55-62. [DOI: 10.22467/jwmr.2023.02733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/01/2023] [Indexed: 01/05/2025]
Abstract
Background: Ablative oncologic procedures for colorectal or gynecologic malignancies can result in large skin or tissue volume defects. Although direct closure may be possible, such attempts can lead to postoperative complications such as wound breakdown, organ prolapse, chronic seroma, or infection. Various procedures, from flap surgery to local wound care, can be useful additions to improve patient outcomes.Methods: This study retrospectively reviews cases of patients with multiple comorbidities who had undergone concomitant interventions after pelvic ablative surgery. Various interventions after pelvic ablative surgery, from reconstructing the defect to managing postoperative complications, are described.Results: Careful planning and selection of the reconstruction method can significantly improve patient outcomes. The authors suggest using gluteal flaps for most reconstructive demands.Conclusion: This case series emphasizes the utility of using various flaps, especially the gluteal flap, in reconstructing oncologic defects in the pelvic and perineal regions. The insights gained from this study will hopefully be of assistance to future research and clinical practice, ultimately improving patient outcomes.
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13
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Xue X, Jian C, Fang Y, Luo L, Guo Y, Ling B, Cai M. A short-term study of laparoscopic-dominant individualised levator ani resection in abdominoperineal resection: A retrospective investigation. J Minim Access Surg 2024; 20:55-61. [PMID: 37706404 PMCID: PMC10898643 DOI: 10.4103/jmas.jmas_168_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/23/2022] [Accepted: 02/08/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVE The objective is to investigate if laparoscopic-dominant abdominoperineal resection (LDAPR) with individualised levator ani resection inhibits local recurrence (LR) and prolongs survival as compared to laparoscopic abdominoperineal resection (APR). MATERIALS AND METHODS Rectal cancer surgery cases were retrospectively identified from September 2014 to December 2019. LDAPR-treated group (55 patients) and the APR-treated group (71 patients) were included in the study. The operation time, circumferential resection margin (CRM), intraoperative tumor surgery (ITP), post-operative complications, the 2-year overall survival (OS) and LR were compared in the two groups. RESULTS The CRM and ITP were significantly reduced in the LDAPR as compared to the APR group (3.6% vs. 16.9%, t = 5.522, P = 0.019; 3.6% vs. 14.1%, t = 3.926, P = 0.048). In terms of post-operative complications, the incidence of urinary retention in LDAPR was significantly reduced than the APR group (10.9% vs. 25.4%, χ2 = 4.139, P = 0.041). Similarly, perineal pain at 6 months or 1 year after surgery was significantly down-regulated in LDAPR than in the APR group (72.7% vs. 88.7%, χ2 = 5.320, P = 0.021; 18.2% vs. 43.2%, χ2 = 8.288, P = 0.004). However, there was no statistically significant difference in the post-operative complications between the LDAPR and APR groups. Finally, LDAPR led to a significantly improved 2-year OS and a reduced LR compared to APR. CONCLUSION LDAPR reduces CMR, ITP and LR and simplified the perineum operation, subsequently protecting the pelvic autonomic nerves. Compared to the conventional APR, LDAPR is a promising procedure worth adopting for rectal cancer treatment.
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Affiliation(s)
- Xiajuan Xue
- Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
| | - Chao Jian
- Internal Medicine ICU, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
| | - Yicong Fang
- Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
| | - Lixiong Luo
- Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
| | - Yinzong Guo
- Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
| | - Bijuan Ling
- Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
| | - Mingzhi Cai
- Colorectal Surgery, Zhangzhou Municipal Hospital Affiliated of Fujian Medical University, Xiangcheng, Zhangzhou, Fujian, China
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14
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Vaesen Bentein H, De Roeck L, Pirenne Y, Vissers G, Tondu T, Thiessen F, Willemsen P. Perineal bowel evisceration after extralevator abdominoperineal excision and vertical rectus abdominis myocutaneous flap closure. Acta Chir Belg 2023; 123:673-678. [PMID: 35786301 DOI: 10.1080/00015458.2022.2097991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/30/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Perineal bowel evisceration is a rare complication after extralevator abdominoperineal excision (ELAPE). This surgical technique is used to resect low rectal and anal cancer, with a lower likelihood of positive surgical margins, but resulting in a larger perineal defect. A vertical rectus abdominis myocutaneous (VRAM) flap allows filling of the empty pelvic space and closure of the defect in the pelvic floor. CASE PRESENTATION A 77-year-old woman, with a hysterectomy in her medical history, underwent an ELAPE followed by reconstruction of the perineal defect with a VRAM flap after neoadjuvant radiotherapy for a moderately differentiated invasive adenocarcinoma of the distal rectum. The postoperative course was complicated with a herniation of the perineal wound and evisceration of a bowel loop. CONCLUSION Closure of the perineal defect after ELAPE remains a challenge, especially in cases where several risk factors for delayed wound healing, flap failure and perineal herniation are present.
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Affiliation(s)
| | - Lynn De Roeck
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim and University Hospital Antwerp, Antwerp, Belgium
| | - Yves Pirenne
- Department of General and Abdominal Surgery, ZNA Middelheim, Antwerp, Belgium
| | - Gino Vissers
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim and University Hospital Antwerp, Antwerp, Belgium
| | - Thierry Tondu
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim and University Hospital Antwerp, Antwerp, Belgium
| | - Filip Thiessen
- Department of Plastic, Reconstructive and Aesthetic Surgery, ZNA Middelheim and University Hospital Antwerp, Antwerp, Belgium
| | - Paul Willemsen
- Department of General and Abdominal Surgery, ZNA Middelheim, Antwerp, Belgium
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15
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van Kessel CS, Waller J, Steffens D, Lee PJ, Austin KKS, Stalley PD, Solomon MJ. Improving Surgical Outcomes in Pelvic Exenteration Surgery: Comparison of Prone Sacrectomy With Anterior Cortical Sacrectomy Techniques. Ann Surg 2023; 278:945-953. [PMID: 37485983 DOI: 10.1097/sla.0000000000006040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes. BACKGROUND In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes. METHODS A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed. RESULTS A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time ( P <0.01) and more blood loss ( P <0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections ( P <0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) ( P =0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively ( P =0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS. CONCLUSIONS Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.
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Affiliation(s)
- Charlotte S van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jacob Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter J Lee
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul D Stalley
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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16
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Lee MH, Kim DH. Low Rectal Cancers at Initial Staging MRI. Radiographics 2023; 43:e230080. [PMID: 37796727 DOI: 10.1148/rg.230080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Low rectal cancers, which are associated with increased risk of local recurrent disease and poorer prognosis, have unique anatomic considerations and issues for staging and treatment that do not apply to mid and high rectal cancers. Although tumor histology help drive the staging and treatment of all rectal cancers, it is of particular importance in low rectal cancers, which may involve the anal canal, to help establish whether a low rectal mass should be staged and treated as a rectal cancer (ie, adenocarcinoma) or an anal cancer (ie, squamous cell carcinoma). Optimal staging and treatment of rectal cancer are contingent on tumor location and local extent, which help guide management decisions including neoadjuvant therapy and curative surgical treatment strategies. Tumor location in the low rectum and local involvement of the anal canal, sphincter, and pelvic floor help determine whether a patient can undergo sphincter-preserving resection such as a low anterior resection versus abdominoperineal resection to achieve negative surgical margins. Issues exist related to the anatomy and patterns of disease spread that are unique to the low rectum and include how to determine and stage anal sphincter involvement, mesorectal fascia status at the pelvic floor, and nodal status of extramesorectal nodes such as the external iliac and inguinal lymph nodes. For these reasons, it is imperative that radiologists who interpret rectal cancer staging MRI examinations feel comfortable with the unique anatomy of the low rectum and anal canal, nuances of low rectal cancer local disease spread, and treatment paradigms for low rectal cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Gollub in this issue.
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Affiliation(s)
- Matthew H Lee
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792
| | - David H Kim
- From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792
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17
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Tschann P, Brock T, Weigl MP, Clemens P, Brunner W, Attenberger C, Königsrainer I, Emmanuel K, Konschake M, Jäger T. Tumour, narrow pelvis and surgery specific factors for total mesorectal excision quality and morbidity following rectal cancer resection. BJS Open 2023; 7:zrad114. [PMID: 38006203 PMCID: PMC10674077 DOI: 10.1093/bjsopen/zrad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/23/2023] [Accepted: 09/19/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Pelvic anatomy is critical in challenging rectal resections. This study investigated how pelvic anatomy relates to total mesorectal excision (TME) quality, anastomotic leakage rate, and long-term oncological outcomes. METHODS Patients undergoing elective rectal cancer resection from 2008 to 2017 in an Austrian institution were retrospectively reviewed regardless of the surgical approach. CT scans were analysed for pelvic measurements and volumes. The primary outcomes of interest were the correlation between pelvic dimensions and the TME quality and anastomotic leakage. Subanalysis was done by surgical approach (open, laparoscopic, transanal TME). Secondary outcomes were overall and disease-free survivals. RESULTS Among 154 eligible patients, 112 were included. The angle between pubic symphysis and promontory significantly correlated with worse TME grades (TME grade 1: mean(s.d.) 102.7(5.7)°; TME grade 2: 92.0(4.4)°; TME grade 3: 91.4(3.6)°; P < 0.001). A significantly lower distance between tumour and circumferential resection margin (CRM) was observed in grade 3 resections, whereas no difference appeared in grade 1 and grade 2 resection (TME grade 1: mean(s.d.) 11.92(9.4) mm; TME grade 2: 10.8(8.1) mm; TME grade 3: 3.1(4.1) mm; P = 0.003). The anastomotic leakage rate was significantly higher in case of a lower CRM (patients with anastomotic leakage: mean(s.d.) 6.8(5.8) mm versus others: 12.6(9.8) mm, P = 0.027), but not associated with pelvimetry measurements. The transanal TME (TaTME) subgroup displayed a wider angle between the pubic symphysis and promontory, younger age and improved TME quality compared to others (respectively, mean TME grades in TaTME versus open versus laparoscopic: 1.0 ± 0.0, 1.5 ± 0.7 and 1.3 ± 0.5, P = 0.013). Finally, oncological survival was not impacted by pelvic measurements or worse TME quality. CONCLUSION The angle between the pubic symphysis and promontory and the distance between tumour and CRM were associated with worse TME grades. The anastomotic leakage was associated with a lower CRM but not with pelvimetric measures.
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Affiliation(s)
- Peter Tschann
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Thomas Brock
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Markus P Weigl
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Patrick Clemens
- Department of Radio-Oncology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Walter Brunner
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Attenberger
- Institute of Medical Physics, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
- Department of Medical Science, Private University in the Principality Liechtenstein, Triesen, Liechtenstein
| | - Ingmar Königsrainer
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Marko Konschake
- Institute of Clinical and Functional Anatomy, Medical University Innsbruck (MUI), Innsbruck, Austria
| | - Tarkan Jäger
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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Assi H, Guné H, Buchwald P, Lagergren J, Lydrup ML, Öberg M. A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5317. [PMID: 37817923 PMCID: PMC10561799 DOI: 10.1097/gox.0000000000005317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023]
Abstract
Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.
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Affiliation(s)
- Hanin Assi
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Henrik Guné
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Jakob Lagergren
- Department of Surgery, Capio S:t Göran Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Marie-Louise Lydrup
- From the Department of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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19
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Shen Y, Yang TH, Deng X, Wu Q, Wei M, Meng W, Wang ZQ. Closure of pelvic peritoneum with bladder peritoneum flap reconstruction after laparoscopic extralevator abdominoperineal excision: A prospective stage II study. J Surg Oncol 2023; 128:851-859. [PMID: 37462103 DOI: 10.1002/jso.27382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Extralevator abdominoperineal resection (ELAPE) has increased perineal wound complications due to the extended resection area. Closure of the pelvic peritoneum (CPP) may exclude the abdominal content from descending into the pelvic cavity and reduce the incidence of perineal complications after ELAPE. We have previously introduced bladder peritoneum flap reconstruction (BLAPER) as a novel method for patients in whom traditional CPP is not possible. The aim of the present study was to report the development and preliminary outcomes of BLAPER. METHODS This is a prospective single-arm study at the development and exploration phase and fulfills the IDEAL framework stage II. Ultralow rectal cancer patients with rigid pelvis who underwent ELAPE with BLAPER were enrolled. Primary outcomes were intraoperative complications and postoperative complications within 1 month after surgery. RESULTS Among 27 patients included, the overall success rate of BLAPER was 96.3% (26/27). Indocyanine green fluorescence imaging and antiadhesive barrier placement were introduced to improve the BLAPER technique. The incidence of major pelvic wound complications was 7.7%. No patient who underwent BLAPER has suffered small bowel obstruction (SBO), presence of small bowel in the retrourogenital space, or perineal hernia (PH). CONCLUSIONS BLAPER is safe and may prevent the small bowel from descending into the retrourogenital space and subsequently developing PH and SBO without increasing the intraoperative and postoperative complications. BLAPER may serve as an option when the primary suture of the pelvic peritoneum is not feasible.
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Affiliation(s)
- Yu Shen
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ting-Han Yang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangbing Deng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zi-Qiang Wang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Loreti A, Arelli F, Spallone D, Bruno E, Abate O. The use of the internal pudendal artery perforator flap after abdominoperineal reconstruction: A single center study. J Plast Reconstr Aesthet Surg 2023; 84:87-92. [PMID: 37327737 DOI: 10.1016/j.bjps.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 06/18/2023]
Abstract
Abdominoperineal resection (APR) is still a valuable option in the presence of cancer recurrences or salvage surgery. Primary perineal closure after conventional APR curries a high rate of wound complications. A multidisciplinary approach with perineal soft tissue reconstruction surgical time improves the immediate and long-term prognosis of these patients. The aim of the study is to report our experience with the use of the internal pudendal artery perforator flap in perineal region reconstruction after APR. We performed 11 perineal region reconstructions after conventional APR between September 2016 and December 2020. In 8 cases the reconstruction was performed on previously irradiated tissues while in 2 cases the radiotherapy was carried out on the perineal tissues solely for adjuvant therapy. A rotation perforating flap was harvested in 8 cases, an advance island flap in 2 cases, and a propeller type in one case. All 11 flaps survived with no immediate postoperative major complications. Only one case showed dehiscence of the donor site wound healed with conservative treatment. Average hospitalization time was 11 days internal pudendal artery perforator flap represents a valid and reliable reconstructive solution after APR showing low complication rates and minimal donor site morbidity even in patients with previous radiotherapy.
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Affiliation(s)
- Andrea Loreti
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Floriana Arelli
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Diana Spallone
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
| | - Edoardo Bruno
- Department of Surgery ''P.Valdoni'', Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Via Giovanni Maria Lancisi, 2, 00161 Roma, Italy.
| | - Ornella Abate
- Plastic Reconstructive Surgery Division, San Giovanni-Addolorata, Via dell'Amba Aradam, 9, 00184 Rome, Italy
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21
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Pellegrin A, Pasinato G, Regimbeau JM, Sabbagh C. Purse string closure of perineal defects after abdominoperineal excision. Langenbecks Arch Surg 2023; 408:309. [PMID: 37580449 DOI: 10.1007/s00423-023-03044-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE The aim of this study was to describe a new technique of perineal closure following abdominoperineal excision (APE) using purse-string perineal skin closure (PSPC). MATERIAL AND METHODS Between January 2016 and May 2021, 15 consecutives patients who had an APE procedure were included in this retrospective single-center study. All indications of APE were considered, as well as all types of APE. We analyzed the patient characteristics and peri-operative features, including overall (Clavien 1 to 5) and severe (Clavien 3 and 4) postoperative morbidity, length of stay (LOS), and long-term results (median time to perineal wound closure and rate of perineal incisional hernia). RESULTS The patients included 11 men and four women, with a mean age of 64 ± 13 [33-80] years. The indication of APE was an epidermoid carcinoma of the anal canal (n = 5) or an adenocarcinoma of the rectum (n = 10). The mean operating time was 220 ± 88.64 [70-360] min. The overall morbidity rate was 60%, the severe morbidity rate 26%, and reoperation rate 26%. The median length of stay was 9 ± 6.5 days. After a mean follow-up of 23.5 ± 20.3 months, the median time to perineal wound closure was 96 ± 60 days, the persistent perineal sinus rate was 6% (n = 2), and one patient developed a perineal incisional hernia. CONCLUSION Purse-string closure of perineal wounds is a safe and effective technique for perineal wound closure after APE. The short LOS allowed an early return home.
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Affiliation(s)
- Alexandra Pellegrin
- Department of Digestive Surgery, Amiens University Hospital, Rond Point du Pr Cabrol, 80054, Amiens, France
| | - Gaétan Pasinato
- Department of Digestive Surgery, Amiens University Hospital, Rond Point du Pr Cabrol, 80054, Amiens, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Rond Point du Pr Cabrol, 80054, Amiens, France
- UR UPJV 7518, SSPC (Simplification of Surgical Patients Care), University of Picardie Jules Verne, Amiens, France
| | - Charles Sabbagh
- Department of Digestive Surgery, Amiens University Hospital, Rond Point du Pr Cabrol, 80054, Amiens, France.
- UR UPJV 7518, SSPC (Simplification of Surgical Patients Care), University of Picardie Jules Verne, Amiens, France.
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22
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Faier TAS, Queiroz FL, Lacerda-Filho A, Paiva RA, França Neto PR, Cortes MGW, Carvalho ARDE, Pereira BMT. Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision. Rev Col Bras Cir 2023; 50:e20233435. [PMID: 37531500 PMCID: PMC10508657 DOI: 10.1590/0100-6991e-20233435-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 03/28/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). METHODS we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. RESULTS sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). CONCLUSION rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.
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Stelzner S, Heinze T, Heimke M, Gockel I, Kittner T, Brown G, Mees ST, Wedel T. Beyond Total Mesorectal Excision: Compartment-based Anatomy of the Pelvis Revisited for Exenterative Pelvic Surgery. Ann Surg 2023; 278:e58-e67. [PMID: 36538640 DOI: 10.1097/sla.0000000000005715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes. BACKGROUND Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself. MATERIALS AND METHODS Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest. RESULTS All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated. CONCLUSIONS A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.
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Affiliation(s)
- Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tillmann Heinze
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - Marvin Heimke
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Kittner
- Department of Radiology, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - Gina Brown
- Department of Surgery and Cancer, Gastrointestinal Imaging, Imperial College, London, UK
| | - Sören T Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - Thilo Wedel
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
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Thiel JT, Welskopf HL, Yurttas C, Farzaliyev F, Daigeler A, Bachmann R. 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. Cancers (Basel) 2023; 15:3345. [PMID: 37444455 DOI: 10.3390/cancers15133345] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/29/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- J T Thiel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, University of Tuebingen, 72076 Tuebingen, Germany
| | - H L Welskopf
- General, Visceral and Transplantation Surgery, Eberhard-Karl-Universität, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - C Yurttas
- General, Visceral and Transplantation Surgery, Eberhard-Karl-Universität, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - F Farzaliyev
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, University of Tuebingen, 72076 Tuebingen, Germany
| | - A Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, University of Tuebingen, 72076 Tuebingen, Germany
| | - R Bachmann
- General, Visceral and Transplantation Surgery, Eberhard-Karl-Universität, University Hospital Tübingen, 72076 Tuebingen, Germany
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Gielen AHC, Colier E, Qiu SS, Keymeulen KBMI, Stassen LPS, Melenhorst J. Research highlight: surgical outcomes of gluteal VY plasty after extensive abdominoperineal resection or total pelvic exenteration. Langenbecks Arch Surg 2023; 408:157. [PMID: 37088846 PMCID: PMC10123027 DOI: 10.1007/s00423-023-02896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/13/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To describe a suitable alternative technique for reconstruction of the pelvic floor after extensive resection. To review our outcomes of gluteal VY plasty in the reconstruction of the pelvic floor after extensive abdominoperineal resection (conventional or extralevator abdominoperineal resection, total pelvic exenteration, or salvage surgery). DESIGN Retrospective cohort study. SETTING An academic hospital and tertiary referral centre for the treatment of locally advanced or locally recurrent rectal cancer, and salvage surgery in The Netherlands. PATIENTS Forty-one consecutive patients who underwent a pelvic floor reconstruction with gluteal VY plasty at Maastricht University Medical Centre between January 2017 and February 2021 were included. The minimum duration of follow-up was 2 years. MAIN OUTCOME MEASURES Perineal herniation is the primary outcome measure. Furthermore, the occurrence of minor and major postoperative complications and long-term outcomes were retrospectively assessed. RESULTS Thirty-five patients (85.4%) developed one or more complications of whom twenty-one patients experienced minor complications and fourteen patients developed major complications. Fifty-seven percent of complications was not related to the VY reconstruction. Six patients (14.6%) recovered without any postoperative complications during follow-up. Three patients developed a perineal hernia. CONCLUSIONS A gluteal VY plasty is a suitable technique for reconstruction of the pelvic floor after extensive perineal resections resulting in a low perineal hernia rate, albeit the complication rate remains high in this challenging group of patients.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - Evie Colier
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Kristien B M I Keymeulen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands.
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Mège D, de Chaisemartin C, Régis-Marigny L, Poizat F, Meillat H, Zemmour C, Moureau L, Lelong B. Supine bottom-up extralevator abdominoperineal excision for anorectal adenocarcinoma is not inferior to standard approach and may be thus safely performed. Surg Endosc 2023:10.1007/s00464-021-08982-1. [PMID: 36952048 DOI: 10.1007/s00464-021-08982-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/31/2021] [Indexed: 03/24/2023]
Abstract
BACKGROUND Extralevator abdominoperineal excision (APE) for rectal carcinoma has been described in order to improve pathological and oncological results compared to standard APE. To obtain the same oncological advantages as extralevator APE, we have previously described a new procedure starting by a perineal approach: the supine bottom-up APE. Our objective is to compare oncological and surgical outcomes between the supine bottom-up APE and the standard APE. METHODS All patients with low rectal adenocarcinoma requiring APE were retrospectively included and divided into 2 groups: supine bottom-up APE (Group A) and standard APE (Group B). RESULTS From 2008 to 2016, 61 patients were divided into Groups A (n = 30) and B (n = 31). Postoperative outcomes and median length of stay were similar between groups. Patients from Group A had a significantly longer distal margin (30 [8-120] vs. 20 [1.5-60] mm, p = 0.04) and higher number of harvested lymph nodes (14.5 [0-33] vs. 11 [5-25], p = 0.03) than those from Group B. Circumferential resection margin involvement was similar between groups (28 vs. 22%, p = 0.6), whereas tumors from Group A were significantly larger and more frequently classified as T4 than those from Group B. Operative time was significantly shorter in Group A (437.5 [285-655] minutes) than in Group B (537.5 [361-721] minutes, p = 0.0009). At the end of follow-up, local recurrence occurred in 7 and 16% of patients from Groups A and B (p = 0.68). Three-year overall and disease-free survival rates were similar between groups (87 vs. 90%, p = 0.62 and 61 vs. 63%, p = 0.88, respectively). CONCLUSION Our findings suggest that supine bottom-up APE doesn't impair surgical outcomes, pathological results, overall and disease-free survivals in comparison with standard APE. This new procedure may be thus safely performed and decrease the operative time. Further randomized multicentric studies are required to confirm these results.
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Affiliation(s)
- Diane Mège
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Cécile de Chaisemartin
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France.
| | - Laure Régis-Marigny
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Flora Poizat
- Department of Biopathology, Institut Paoli-Calmettes, Marseille, France
| | - Hélène Meillat
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Innovation, Biostatistics and Methodology Unit, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | - Laurence Moureau
- Radiation Oncology Department, Institut Paoli Calmettes, Marseille, France
| | - Bernard Lelong
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
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A V–Y fasciocutaneous flap for perineal reconstruction following abdominoperineal resection: quicker and better than a myocutaneous gluteal flap? EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-022-02035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Abstract
Background
Abdominoperineal resection in patients with anorectal malignancies may require flap reconstruction for large perineal defects as an adjunct to the oncologic surgery. Perineal reconstruction should be timely, safe, and yield good long-term functional results. There is no agreement on the ideal approach.
Methods
We performed a retrospective observational cohort study to compare clinical outcomes and post-operative complications between a musculocutaneous gluteal flap and a fasciocutaneous V–Y flap for perineal reconstruction. We included all patients who underwent abdominoperineal resection at Karolinska University Hospital between 2016 and 2019. Patient demographics and comorbidities, as well as treatment data, post-operative complications, and follow-up data, were collected from medical records.
Results
A total of 44 patients were included with a mean age of 65 years where 73% were men. Reconstruction was made with a musculocutaneous gluteal flap in 19 patients (43%) and with a fasciocutaneous V–Y flap in 25 patients (57%). Flap-related post-operative complications occurred in 39% of the patients and the incidence did not differ between the groups (p = 0.831). Neither operative time, time to ambulant mobility, time to drain removal, nor time to epidural removal differed between the groups (p > 0.05). Four patients in the gluteal flap group and one patient in the V–Y flap group presented with long-term complications.
Conclusions
Post-operative complications are common after perineal reconstruction following abdominoperineal resection regardless of reconstructive approach. Our study confirms that both a fasciocutaneous and a musculocutaneous flap are acceptable options for perineal reconstruction.
Level of evidence: Level III, risk/prognostic study.
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Nagano H, Kajitani R, Ohno R, Munechika T, Matsumoto Y, Takahashi H, Aisu N, Kojima D, Yoshimatsu G, Hasegawa S, Kobayashi H, Sugihara K. Comparison of oncological outcomes between low anterior resection and abdominoperineal resection for rectal cancer: A retrospective cohort study using a multicenter database in Japan. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2467-2474. [PMID: 35752499 DOI: 10.1016/j.ejso.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/16/2022] [Accepted: 06/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND It remains controversial whether the abdominoperineal resection (APR) procedure itself has a negative impact on prognosis compared with sphincter-saving surgery (SSS). The purpose of this study was to investigate whether the operation type affects the prognostic outcome in rectal cancer using a multicenter database in Japan. METHODS The study involved 2533 patients who underwent APR or SSS and were registered in the Japanese Society for Cancer of the Colon and Rectum database, which includes data from 74 centers, between 2003 and 2007. The primary endpoints were overall survival (OS) and relapse-free survival (RFS). The secondary endpoints were local recurrence rate (LRR) and pathological radial margin (pRM) status. RESULTS Multivariate analysis identified pathological tumor depth, lymph node status, and pRM status to be associated with oncological outcomes (OS, RFS, LRR). Although the oncological outcomes were worse after APR than after SSS in univariate analysis, there was no significant difference in OS (hazard ratio 1.08; 95% confidence interval [CI] 0.85-1.37) or RFS (hazard ratio 1.06; 95% CI 0.87-1.30) between APR and SSS. There was also no significant difference in LRR (odds ratio 1.11, 95% CI 0.70-1.77). Multivariate analysis showed that operation type was associated with positive pRM (odds ratio 3.13, 95% CI 0.18-0.56). CONCLUSIONS There was no significant difference in oncological outcomes between APR and SSS for rectal cancer. The risk of positive pRM was higher for APR and performing radial margin-negative surgery is an important factor in improving the oncological outcomes of APR.
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Affiliation(s)
- Hideki Nagano
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Ryuji Kajitani
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Ryo Ohno
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Taro Munechika
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hiroyuki Takahashi
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Daibo Kojima
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago Takatsu-ku, Kawasaki, Kanagawa, 213-8504, Japan
| | - Kenichi Sugihara
- Tokyo Medical and Dental University, 1-5-45 Yushima Bunkyo-ku, Tokyo, 113-8510, Japan
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Pai AA, Young-Sing Q, Bera S, Maheshwari K, Misra A. Analysis of clinical and patient-reported outcomes in post-ELAPE perineal reconstruction with IGAP flap – A 5-year review. JPRAS Open 2022; 34:10-20. [PMID: 36061405 PMCID: PMC9429127 DOI: 10.1016/j.jpra.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/14/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Extralevator abdominoperineal excisions (ELAPE) are now the accepted treatment option for low rectal cancers, which result in large perineal defects necessitating reconstruction. The aim of our study was to assess the clinical outcomes as well as the quality-of-life parameters (QOLP) following these reconstructions. Methods: A series of 27 patients who underwent ELAPE and immediate reconstruction with inferior gluteal artery perforator flaps (IGAP) between December 2013 to December 2018 were retrospectively analysed on patient demographics, disease and treatment, complications, and QOLP. Results: With a mean age of 71.6 years, all patients had low rectal cancers and underwent ELAPE (24 open, 3 lap-assisted) and immediate IGAP flap reconstruction. The follow-up period was 1 year. The overall perineal early minor complication rate was 25.9% and the early major complication rate of 14.8%. QOLP, such as tolerance to sit, perineal pain, perineal aesthetics, showed high patient satisfaction of 77.7%, 40.74%, and 66.6%, respectively at 1 year. The perineal hernia rate was 14.8% with all patients being female (p 0.0407; significant). Conclusion: IGAP flaps are a reliable option for reconstructing post-ELAPE defects with good patient satisfaction and outcomes.
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Affiliation(s)
- Ashwin Alke Pai
- Chang Gung Memorial Hospital, Linkou, Taiwan & Wexham Park Hospital, UK
- Corresponding author: Ashwin Alke Pai; FRCS Plast, No 4A012, 11-5, Wenhua 2nd Road, Guishan District, Taoyuan, Taiwan 333.
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Extralevator Abdominoperineal Excision (ELAPE) is Not Superior to Abdominoperineal Excision (APE) in the Era of Neoadjuvant Treatment in Rectal Cancer. PRILOZI (MAKEDONSKA AKADEMIJA NA NAUKITE I UMETNOSTITE. ODDELENIE ZA MEDICINSKI NAUKI) 2022; 43:21-27. [PMID: 36473043 DOI: 10.2478/prilozi-2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim: To evaluate the effect of extralevator abdominoperineal excision of the rectum (ELAPE) on the circumferential resection margin (CRM) and overall survival in comparison to standard abdominoperineal excision of the rectum (APE) in patients with advanced rectal cancer. Material and Methods: This retrospective study encompasses patients with advanced rectal cancer operated on with two different methods: prone Jack-Knife position ELAPE and APE. In part of them, neoadjuvant chemoradiation was conducted. Postoperative patient, tumor, and outcome data were analyzed in terms of differences in CRM positivity and overall survival. Results: Of 67 patients treated with either APE (52) or ELAPE (15), 43 were male and 24 were female. Neoadjuvant treatment was conducted on 49 of the total patients. Complete pathological response (T0) was achieved in 3 patients. Positive CRM was reported in 7 patients (11.5 %), 3 in ELAPE and 4 in APE group (p = 0.348). The overall postoperative complication rate was 56.7%. Mean survival period was 42.2 months. Overall survival rate for both groups was 67.2 %. No statistical differences were seen between the ELAPE and APE procedure in terms of overall survival (p = 0.483). Conclusions: Differences between the use of ELAPE and APE in terms of CRM positivity and overall survival were not statistically significant. Therefore, we conclude that ELAPE is not superior to standard APE in the treatment of advanced rectal cancer.
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A Comparison of Perineal Myocutaneous Flaps Following Abdominoperineal Excision of the Rectum for Anorectal Pathology. Dis Colon Rectum 2022; 65:1316-1324. [PMID: 35156364 DOI: 10.1097/dcr.0000000000002271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types. OBJECTIVE To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology. DESIGN This was a retrospective comparative study. SETTING This study was conducted at a large, tertiary referral institution. PATIENTS Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded. MAIN OUTCOME MEASURES The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques. RESULTS A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05). LIMITATIONS This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size. CONCLUSION Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal. ANTECEDENTES La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.
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Stelzner S. Perineale Hernien nach endoskopischer abdominoperinealer Exzision eines Rektumkarzinoms. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00627-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sun S, Sun S, Zheng X, Yu J, Wang W, Gong Q, Zhao G, Li J, Zhang H. Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment. BMC Cancer 2022; 22:916. [PMID: 36002810 PMCID: PMC9404665 DOI: 10.1186/s12885-022-10019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Extralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes. Methods Medical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed. Results The mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%. Conclusions Laparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10019-2.
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Affiliation(s)
- Shaowei Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Shengbo Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Xiangyun Zheng
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jiangtao Yu
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Wenchang Wang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Qing Gong
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Guowei Zhao
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jing Li
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China.
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Shah R, Kamble R, Herieka M, Dalal M. A National Survey on Perineal Reconstruction Following Standard and Extralevator Abdominoperineal Excision: Current Practices and Trends in the UK. Cureus 2022; 14:e28339. [PMID: 36034060 PMCID: PMC9400553 DOI: 10.7759/cureus.28339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/05/2022] Open
Abstract
Background Challenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have given rise to an emerging multidisciplinary approach between colorectal and plastic surgeons. At present, there is a relative paucity of evidence on best practice. This study sought to assess current national practice concerning perineal reconstruction following APE/ELAPE in the United Kingdom (UK) and to determine the factors involved in reconstruction choice. Methodology An anonymised survey was circulated to consultant plastic surgeons at all 48 UK centres performing perineal reconstruction following APE/ELAPE. Responses were collected between October 2021 and April 2022. Results Complete responses were received from 24 units nationally. All units had a dedicated APE/ELAPE service. Overall, 70% adopted a standardised reconstructive approach, the most common being the inferior gluteal artery perforator flap (n = 11). Significant variation was identified in the reconstructive technique. Similar differences were observed in the perceived importance of surgical factors guiding the reconstructive decision-making process, the top priorities being the size of the defect and previous radiotherapy. Conclusions The variability of responses suggests a lack of national consensus on optimal reconstruction following APE/ELAPE, despite the majority of centres employing a standardised approach to reconstruction. Our study highlights important surgical decision-making factors and provides valuable insight to aid in developing national collaborative evidence-based guidelines on best practice.
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Salmenkylä T, Kilpivaara K, Ohtonen P, Rautio T, Mäkäräinen E. Case control study investigating the clinical utility of NPWT in the perineal region following abdominoperineal resection for rectal adenocarcinoma: a single center study. BMC Surg 2022; 22:296. [PMID: 35907824 PMCID: PMC9338595 DOI: 10.1186/s12893-022-01746-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/22/2022] [Indexed: 11/15/2022] Open
Abstract
Background Perineal wound complications are common after abdominoperineal resection (APR) for rectal adenocarcinoma. Delayed wound healing may postpone postoperative adjuvant therapy and, therefore, lead to a worse survival rate. Negative-pressure wound therapy (NPWT) has been suggested to improve healing, but research on this subject is limited. Methods The aim of this study was to assess whether NPWT reduces surgical site infections (SSI) after APR for rectal adenocarcinoma when the closure is performed with a biological mesh and a local flap. A total of 21 consecutive patients had an NPWT device (Avelle, Convatec™) applied to the perineal wound. The study patients were compared to a historical cohort in a case–control setting in relation to age, body mass index, tumor stage, and length of neoadjuvant radiotherapy. The primary outcome was the surgical site infection rate. The secondary outcomes were the wound complication rate, the severity of wound complications measured by the Clavien–Dindo classification, length of hospital stay, and surgical revision rate. Results The SSI rate was 33% (7/21) in the NPWT group and 48% (10/21) in the control group, p = 0.55. The overall wound complication rate was 62% (13/21) in NPWT patients and 67% (14/21) in the control group, p > 0.90. The length of hospital stay was 15 days in the NPWT group and 13 in the control group, p = 0.34. The wound severity according to the Clavien–Dindo classification was 3b in 29% (6/21) of the NPWT group and in 38% (8/21) of the control group. A surgical revision had to be performed in 29% (6/21) of the cases in the NPWT group and 38% (8/21) in the control group, p = 0.73. Conclusion NPWT did not statistically decrease surgical site infections or reduce wound complication severity in perineal wounds after APR in this case–control study. The results may be explained by technical difficulties in applying NPWT in the perineum, especially in female patients. NPWT devices should be further developed to suit the perineal anatomy before their full effect can be assessed. Trial registration The study was registered as a prospective registry study (266/2018, registered 15th of November 2018)
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Affiliation(s)
- Tellu Salmenkylä
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland.
| | - Katariina Kilpivaara
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Research Service Unit, Oulu University Hospital, Oulu, Finland.,The Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Oulu, Finland
| | - Tero Rautio
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Elisa Mäkäräinen
- Department of Surgery, Medical Research Center, Oulu University Hospital, Oulu, Finland
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Jackisch J, Jackisch T, Roessler J, Sims A, Nitzsche H, Mann P, Mees ST, Stelzner S. Tailored concept for the plastic closure of pelvic defects resulting from extralevator abdominoperineal excision (ELAPE) or pelvic exenteration. Int J Colorectal Dis 2022; 37:1669-1679. [PMID: 35750763 DOI: 10.1007/s00384-022-04196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE No standard exists for reconstruction after extralevator abdominoperineal excision (ELAPE) and pelvic exenteration. We propose a tailored concept with the use of bilateral gluteal V-Y advancement flaps in non-extended ELAPE and with vertical myocutaneous rectus abdominis muscle (VRAM) flaps in extended procedures. This retrospective study analyzes the feasibility of this concept. PATIENTS AND METHODS We retrieved all consecutive patients after ELAPE or pelvic exenteration for rectal, anal, or vulva cancer with flap repair from a prospective database. Perineal wound complications were defined as the primary endpoint. Outcomes for the two different flap reconstructions were analyzed. RESULTS From 2005 to 2021, we identified 107 patients who met the study criteria. Four patients underwent exenteration with VRAM flap repair after previous V-Y flap fashioning. Therefore, we report on 75 V-Y and 36 VRAM flaps. The V-Y group contained more rectal carcinomas, and the VRAM group exhibited more patients with recurrent cancer, more multivisceral resections, and longer operation times. Perineal wound complications occurred in 21.3% in the V-Y group and in 36.1% in the VRAM group (p = 0.097). Adjusted odds ratio for perineal wound complication was not significantly different for the two flap types. CONCLUSION Concerning perineal wound complications, our concept yields favorable results for V-Y flap closure indicating that this less invasive approach is sufficient for non-extended ELAPE. Advantages are a shorter operation time, less donor site morbidity, and the option of a second repair. VRAM flaps were reserved for larger wounds after pelvic exenteration or vaginal repair.
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Affiliation(s)
- Julia Jackisch
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Thomas Jackisch
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Joerg Roessler
- Clinic for Plastic and Aesthetic Surgery, Oberer Kreuzweg 8, Dresden, D-01097, Germany
| | - Anja Sims
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Holger Nitzsche
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Pia Mann
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Sören Torge Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany
| | - Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, Dresden, D-01067, Germany. .,Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, Leipzig, D-04103, Germany.
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Zhang H, Li G, Cao K, Zhai Z, Wei G, Ye C, Zhao B, Wang Z, Han J. Long-term outcomes after extra-levator versus conventional abdominoperineal excision for low rectal cancer. BMC Surg 2022; 22:242. [PMID: 35733206 PMCID: PMC9219120 DOI: 10.1186/s12893-022-01692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Extralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is achieved in patients undergoing ELAPE, the long-term benefits have not been established. In this study we evaluated the safety, pathological and survival outcomes in rectal cancer patients who underwent ELAPE and APE. METHODS One hundred fourteen patients were enrolled, including 68 in the ELAPE group and 46 in the APE group at the Beijing Chaoyang Hospital, Capital Medical University from January 2011 to November 2020. The baseline characteristics, overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS) were calculated and compared between the two groups. RESULTS Demographics and tumor stage were comparable between the two groups. The 5-year PFS (67.2% versus 38.6%, log-rank P = 0.008) were significantly improved in the ELAPE group compared to the APE group, and the survival advantage was especially reflected in patients with pT3 tumors, positive lymph nodes or even those who have not received neoadjuvant chemoradiotherapy. Multivariate analysis showed that APE was an independent risk factor for OS (hazard ratio 3.000, 95% confidence interval 1.171 to 4.970, P = 0.004) and PFS (hazard ratio 2.730, 95% confidence interval 1.506 to 4.984, P = 0.001). CONCLUSION Compared with APE, ELAPE improved long-term outcomes for low rectal cancer patients, especially among patients with pT3 tumors, positive lymph nodes or those without neoadjuvant chemoradiotherapy.
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Affiliation(s)
- Haoyu Zhang
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Ganbin Li
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Ke Cao
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Zhiwei Zhai
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Guanghui Wei
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Chunxiang Ye
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Baocheng Zhao
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Zhenjun Wang
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China.
| | - Jiagang Han
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China.
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Lehtonen TM, Koskenvuo LE, Seppälä TT, Lepistö AH. The prognostic value of extramural venous invasion in preoperative MRI of rectal cancer patients. Colorectal Dis 2022; 24:737-746. [PMID: 35218137 PMCID: PMC9314139 DOI: 10.1111/codi.16103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/07/2021] [Accepted: 02/18/2022] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to examine the prognostic value of extramural venous invasion observed in preoperative MRI on survival and recurrences. METHOD In total, 778 rectal cancer patients were evaluated in multidisciplinary meetings in Helsinki University Hospital during the years 2016-2018. 635 patients met the inclusion criteria of stage I-III disease and were intended for curative treatment at the time of diagnosis. 128 had extramural venous invasion in preoperative MRI. RESULTS The median follow-up time was 2.5 years. In a univariate analysis extramural venous invasion was associated with poorer disease-specific survival (hazard ratio [HR] 2.174, 95% CI 1.118-4.224, P = 0.022), whereas circumferential margin ≤1 mm, tumour stage ≥T3c or nodal positivity were not. Disease recurrence occurred in 17.3% of the patients: 13.4% had metastatic recurrence only, 1.7% mere local recurrence and 2.2% both metastatic and local recurrence. In multivariate analysis, extramural venous invasion (HR 1.734, 95% CI 1.127-2.667, P = 0.012) and nodal positivity (HR 1.627, 95% CI 1.071-2.472, P = 0.023) were risk factors for poorer disease-free survival (DFS). Circumferential margin ≤1 mm was a risk factor for local recurrence in multivariate analysis (HR 5.675, 95% CI 1.274-25.286, P = 0.023). CONCLUSION In MRI, circumferential margin ≤1 mm is a risk factor for local recurrence, but the risk is quite well controlled with chemoradiotherapy and extended surgery. Extramural venous invasion instead is a significant risk factor for poorer DFS and new tools to reduce the systemic recurrence risk are needed.
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Affiliation(s)
- Taru M. Lehtonen
- Department of SurgeryHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Laura E. Koskenvuo
- Department of SurgeryHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Toni T. Seppälä
- Department of SurgeryHelsinki University Hospital and University of HelsinkiHelsinkiFinland,Applied Tumor Genomics, Research Programs UnitUniversity of HelsinkiFinland
| | - Anna H. Lepistö
- Department of SurgeryHelsinki University Hospital and University of HelsinkiHelsinkiFinland,Applied Tumor Genomics, Research Programs UnitUniversity of HelsinkiFinland
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Mathew DAP, Wagh DMS. Abdominoperineal Excision in current era. Cancer Treat Res Commun 2022; 32:100580. [PMID: 35668011 DOI: 10.1016/j.ctarc.2022.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
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40
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Mori GA, Tiernan JP. Management of Perineal Wounds Following Pelvic Surgery. Clin Colon Rectal Surg 2022; 35:212-220. [PMID: 35966381 PMCID: PMC9374536 DOI: 10.1055/s-0042-1742414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Despite advancements in understanding and technique, there remain significant challenges in the management of a complex perineal wound following pelvic surgery. Complications including wound sepsis, fistulation, persistent sinus, and herniation produce additional morbidity and health care costs. This article details the methods of optimizing patient and operative factors to mitigate this risk, alongside strategies to deal with sequelae of wound failure.
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Affiliation(s)
- George A Mori
- John Goligher Colorectal Unit, St James's University Hospital, Leeds, United Kingdom
| | - Jim P Tiernan
- John Goligher Colorectal Unit, St James's University Hospital, Leeds, United Kingdom
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41
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Lee HG, Kim CW, Lee JL, Yoon YS, Park IJ, Lim SB, Yu CS, Kim JC. Comparative survival risks in patients undergoing abdominoperineal resection and sphincter-saving operation for rectal cancer: a 10-year cohort analysis using propensity score matching. Int J Colorectal Dis 2022; 37:989-997. [PMID: 35378615 DOI: 10.1007/s00384-022-04138-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in patients with rectal cancer. This study compared long-term oncologic outcomes and prognostic parameters in propensity score-matched patients who underwent APR and SSO. METHODS This study analyzed 958 consecutive patients with lower rectal cancer who underwent preoperative chemoradiotherapy followed by APR or SSO between 2005 and 2015. Propensity score matching analysis was performed to adjust baseline characteristics, including clinical stage, tumor distance from the anal verge, and tumor size. RESULTS In the entire cohort, the APR group had larger and lower tumors and showed significantly shorter 5-year disease-free survival (DFS) than the SSO group (64.5% vs. 75.8%, p = 0.01). After propensity score matching, there were no significant between-group differences in local (9.5% vs. 8.0%, p = 0.59) and systemic (27.9% vs. 23.4%, p = 0.3) recurrence rates, and 5-year DFS (67.5% vs. 69.9%, p = 0.49) and overall survival (80.8% vs. 82.9%, p = 0.65) rates. A lower number of lymph nodes retrieved was independently associated with recurrence and survival outcomes in the APR group, whereas poorly differentiated histology was an independent associated parameter in the SSO group. Advanced stage and perineural invasion were identified as independent prognostic parameters in both groups. CONCLUSIONS This study indicated that the long-term oncologic outcomes of APR were comparable to those of SSO. Because prognostic parameters associated with oncologic outcomes differed between the respective procedures, correctable parameters could be ameliorated through complete total mesorectal excision and personalized systemic treatment.
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Affiliation(s)
- Hyun Gu Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Shang A, Wang M, Yang Y, Zhao Z, Li D, Guo Y, Qi R, Yang Y, Wang S. Transperineal pelvic drainage combined with lateral position to promote perineal wound healing after abdominoperineal resection: A prospective cohort trial. Medicine (Baltimore) 2022; 101:e29104. [PMID: 35446293 PMCID: PMC9276168 DOI: 10.1097/md.0000000000029104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND For the rectal cancer <5 cm from anal margin, extralevator abdominoperineal resection (eAPR) has been accepted widely by surgeons. However, the rate of perineal infection following up eAPR is approximately 70%. We did the study with the aim of evaluating the effect and safety of transperineal pelvic drainage combined with lateral position (TPDLP) on perineal wound in patients undergoing eAPR. METHODS Patients were randomly assigned to N-TPDLP group (standard arm) or TPDLP group (intervention arm). In the standard arm, surgery was completed after abdominal drainage tube was placed in pelvic. Comparatively, an additional transperineal wound drainage tube was applied in the experimental arm. Postoperatively, patients of both 2 groups were informed not to sit to reduce perineal compression until the perineal wound healed. But lateral position was demanded in the intervention arm. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of <2 at 30 days postoperatively. Patients were followed for 6 months. RESULTS In total, 60 patients were randomly assigned to standard arm (n = 31) and intervention arm (n = 29). The mean perineal wound healing time was 34.2 (standard deviation [SD] 10.9) days in TPDLP arm, which significantly differ from 56.4 (SD 34.1) in N-TPDLP arm (P = .001). At 30 days postoperatively, 3 (10%) of 29 patients undergoing TPDLP were classified into grade 4 according to Southampton wound score, however, 16 (52%) of 31 patients were classified into grade 4 in control arm, and significantly difference was observed between randomization groups (P = .001). What's more, perineal wound pain was assessed at 30 days postoperatively, and it is discovered that the pain degree of patients in control arm was significantly more severe than the interventive arm (P = .015). CONCLUSION In the present study, we found that TPDLP generated a favorable prognosis for perineal wounds with acceptable side-effects.
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Affiliation(s)
- An Shang
- Department of the General Surgery
| | - Min Wang
- Department of the General Surgery
| | | | | | | | - Yu Guo
- Department of the General Surgery
| | - Rui Qi
- Department of the General Surgery
| | | | - Shuang Wang
- Department of Dermatology, The Second Hospital of Jilin University, Changchun, Jilin, China No. 218, Ziqiang Street, Nanguan District, Changchun City, Jilin Province, China
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Manabe T, Mizuuchi Y, Tsuru Y, Kitagawa H, Fujimoto T, Koga Y, Nakamura M, Noshiro H. Retrospective analysis of risk factors for postoperative perineal hernia after endoscopic abdominoperineal excision for rectal cancer. BMC Surg 2022; 22:88. [PMID: 35260127 PMCID: PMC8903566 DOI: 10.1186/s12893-022-01538-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/28/2022] [Indexed: 12/01/2022] Open
Abstract
Background In contrast to open-surgery abdominoperineal excision (APE) for rectal cancer, postoperative perineal hernia (PPH) is reported to increase after extralevator APE and endoscopic surgery. In this study, therefore, we aimed to determine the risk factors for PPH after endoscopic APE. Methods A total 73 patients who underwent endoscopic APE for rectal cancer were collected from January 2009 to March 2020, and the risk factors for PPH were analyzed retrospectively. Results Nineteen patients (26%) developed PPH after endoscopic APE, and the diagnosis of PPH was made at 9–393 days (median: 183 days) after initial surgery. Logistic regression analysis showed that absence of pelvic peritoneal closure alone increased the incidence of PPH significantly (odds ratio; 13.76, 95% confidence interval; 1.48–1884.84, p = 0.004). Conclusions This preliminary study showed that pelvic peritoneal closure could prevent PPH after endoscopic APE.
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Affiliation(s)
- Tatsuya Manabe
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuhiro Tsuru
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Hiroshi Kitagawa
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Takaaki Fujimoto
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yasuo Koga
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Short-Term Outcomes with Standardized Transperineal Minimally Invasive Abdominoperineal Excision for Rectal Cancer. J Gastrointest Surg 2022; 26:713-719. [PMID: 34608600 DOI: 10.1007/s11605-021-05140-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transperineal abdominoperineal excision (TpAPE) is an emerging approach for low rectal cancers but is technically challenging. Based on an anatomical study we conducted previously, we have standardized the TpAPE procedure. Here, we aimed to validate the feasibility of the standardized TpAPE by investigating the short-term outcomes. METHODS From January 2018 to November 2020, a total of 405 patients underwent laparoscopic or robotic rectal resection for rectal cancer in our institution. For the current study, we analyzed data for the 31 patients who underwent TpAPE. The abdominal phase was performed synchronously with the perineal phase using either a laparoscopic or robotic approach. Short-term outcomes included operative and pathological results. RESULTS Of the 31 cases, we identified anterior quadrant tumor invasion in 21. Most of the cases were advanced, with 6 staged as cT3 and 20 as T4. Of the 27 cases not involving distant metastasis, neoadjuvant therapy was performed in 19. No inadvertent rectal perforation or urethral injury was found intraoperatively. The median procedural duration to specimen removal was 250 min (interquartile range, 204-287), and the median intraoperative blood loss was 10 ml (interquartile range, 5-40). Regarding postoperative complications, perineal wound infection developed in 11 cases. A positive circumferential resection margin was found in 3, corresponding to the positive rate of 9.7%. These three cases were among the first 12 cases involving standardized TpAPE. CONCLUSIONS The current results indicate that TpAPE can be performed safely and might represent a useful option for low rectal cancer resection.
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Segev L, Schtrechman G, Kalady MF, Liska D, Gorgun IE, Valente MA, Nissan A, Steele SR. Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience. Dis Colon Rectum 2022; 65:361-372. [PMID: 34784318 DOI: 10.1097/dcr.0000000000002067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Randomized studies have validated laparoscopic proctectomy for the treatment of rectal cancer as noninferior to an open proctectomy, but most of those studies have included sphincter-preserving resections along with abdominoperineal resection. OBJECTIVE This study aimed to compare perioperative and long-term oncological outcomes between minimally invasive and open abdominoperineal resection. DESIGN This study is a retrospective analysis of a prospectively maintained database. SETTINGS The study was conducted in a single specialized colorectal surgery department. PATIENTS All patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2016 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the perioperative and long-term oncological outcomes. RESULTS We included 452 patients, 372 in the open group and 80 in the minimally invasive group, with a median follow-up time of 74 months. There were significant differences between the groups in terms of neoadjuvant radiation treatment (67.5% of the open versus 81.3% of the minimally invasive group, p = 0.01), operative time (mean of 200 minutes versus 287 minutes, p < 0.0001), and mean length of stay (9.5 days versus 6.6 days, p < 0.0001). Overall complication rates were similar between the groups (34.5% versus 27.5%, p = 0.177). There were no significant differences in the mean number of lymph nodes harvested (21.7 versus 22.2 nodes, p = 0.7), circumferential radial margins (1.48 cm versus 1.37 cm, p = 0.4), or in the rate of involved radial margins (10.8% versus 6.3%, p = 0.37). Five-year overall survival was 70% in the open group versus 80% in the minimally invasive group (p = 0.344), whereas the 5-year disease-free survival rate in the open group was 63.2% versus 77.6% in the minimally invasive group (p = 0.09). LIMITATIONS This study was limited because it describes a single referral institution experience. CONCLUSIONS Although both approaches have similar perioperative outcomes, the minimally invasive approach benefits the patients with a shorter length of stay and a lower risk for surgical wound infections. Both approaches yield similar oncological technical quality in terms of the lymph nodes harvested and margins status, and they have comparable long-term oncological outcomes. See Video Abstract at http://links.lww.com/DCR/B754.RESULTADOS A LARGO PLAZO DE LA RESECCIÓN ABDOMINOPERINEAL MÍNIMAMENTE INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: EXPERIENCIA DE UN SOLO CENTRO ESPECIALIZADOANTECEDENTES:Estudios aleatorizados han validado la proctectomía laparoscópica para el tratamiento del cáncer de recto igual a la proctectomía abierta, pero la mayoría de esos estudios han incluido resecciones con preservación del esfínter junto con resección abdominoperineal.OBJETIVO:Comparar los resultados oncológicos perioperatorios y a largo plazo entre la resección abdominoperineal abierta y mínimamente invasiva.DISEÑO:Análisis retrospectivo de una base de datos mantenida de forma prospectiva.ENTORNO CLINICO:Servicio único especializado en cirugía colorrectal.PACIENTES:Todos los pacientes que se sometieron a resección abdominoperineal por cáncer de recto primario entre 2000 y 2016.PRINCIPALES MEDIDAS DE VALORACION:Resultados oncológicos perioperatorios y a largo plazo.RESULTADOS:Se incluyeron 452 pacientes, 372 en el grupo abierto y 80 en el grupo mínimamente invasivo, con una mediana de seguimiento de 74 meses. Hubo diferencias significativas entre los grupos en términos de tratamiento con radiación neoadyuvante (67,5% del grupo abierto versus 81,3% del grupo mínimamente invasivo, p = 0,01), tiempo operatorio (media de 200 minutos versus 287 minutos, p < 0,0001) y la duración media de la estancia (9,5 días frente a 6,6 días, p < 0,0001). Las tasas generales de complicaciones fueron similares entre los grupos (34,5% versus 27,5%, p = 0,177). No hubo diferencias significativas en el número medio de ganglios linfáticos extraídos (21,7 versus 22,2 ganglios, p = 0,7), márgenes radiales circunferenciales (1,48 cm y 1,37 cm, p = 0,4), ni en la tasa de márgenes radiales afectados (10,8 cm). % versus 6,3%, p = 0,37). La supervivencia general a 5 años fue del 70% en el grupo abierto frente al 80% en el grupo mínimamente invasivo (p = 0,344), mientras que la tasa de supervivencia libre de enfermedad a 5 años en el grupo abierto fue del 63,2% frente al 77,6% en el grupo mínimamente invasivo (p = 0,09).LIMITACIONES:Experiencia en una institución de referencia única.CONCLUSIONES:Si bien ambos tienen resultados perioperatorios similares, el enfoque mínimamente invasivo, beneficia a los pacientes con estadía más corta y menor riesgo de infecciones de la herida quirúrgica. Ambos enfoques, producen una calidad técnica oncológica similar en términos de ganglios linfáticos extraídos y estado de los márgenes, y tienen resultados oncológicos comparables a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B754. (Traducción - Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Lior Segev
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gal Schtrechman
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - I Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Aviram Nissan
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Wolford D, Westcott L, Fleshman J. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2022; 43:101740. [DOI: 10.1016/j.suronc.2022.101740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022]
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Wilkins S, Yap R, Mendis S, Carne P, McMurrick PJ. Surgical Techniques for Abdominoperineal Resection for Rectal Cancer: One Size Does Not Fit All. Front Surg 2022; 9:818097. [PMID: 35284486 PMCID: PMC8907259 DOI: 10.3389/fsurg.2022.818097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Abdominoperineal resection (APR) of rectal cancer is associated with poorer oncological outcomes than anterior resection. This may be due to higher rates of intra-operative perforation (IOP) and circumferential resection margin (CRM) involvement causing higher recurrence rates and surgical complications. To address these concerns, several centers advocated a change in technique from a standard APR to a more radical extra-levator abdominoperineal excision (ELAPE). Initial reports showed that ELAPE reduced IOP rates and CRM involvement but increased wound complications and longer surgical duration. However, many of these studies had unacceptable rates of IOP and CRM before retraining in ELAPE. This may indicate that it was a sub-optimal surgical technique, which improved upon training, that had influenced the high CRM and IOP rates rather than the technique itself. Subsequent studies demonstrated that the CRM involvement rate for ELAPE was not always lower than for standard APR and, in some cases, significantly higher. The morbidity of ELAPE can be high, with studies reporting higher adverse events than APR, especially in terms of wound complications from the larger perineal incision required in ELAPE. Whether ELAPE improves short- or long-term oncological outcomes for patients has not been clearly demonstrated. The authors propose that all centers performing rectal cancer surgery audit surgical outcomes of patients undergoing APR or ELAPE and examine CRM involvement, IOP rates, and local recurrence rates, preferably through a national body. If rates of adverse technical or oncological outcomes exceed acceptable levels, then retraining in the appropriate surgical techniques may be indicated.
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Affiliation(s)
- Simon Wilkins
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- *Correspondence: Simon Wilkins
| | - Raymond Yap
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - Shehara Mendis
- Department of Oncology Research, Cabrini Hospital, Malvern, VIC, Australia
| | - Peter Carne
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Colorectal Unit, Department of Surgery, Alfred Hospital, Melbourne, VIC, Australia
| | - Paul J. McMurrick
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
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Vaginal reconstruction using a gluteal transposition flap after abdominoperineal excision for anorectal malignancy. Updates Surg 2022; 74:467-478. [PMID: 35124788 PMCID: PMC8995290 DOI: 10.1007/s13304-021-01211-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/20/2021] [Indexed: 11/17/2022]
Abstract
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.
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Shen Y, Yang T, Zeng H, Meng W, Wang Z. Is it worthwhile to perform closure of the pelvic peritoneum in laparoscopic extralevator abdominoperineal resection? Langenbecks Arch Surg 2022; 407:1139-1150. [PMID: 35083567 DOI: 10.1007/s00423-021-02412-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 12/14/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE There is no uniformity in the use of closure of the pelvic peritoneum (CPP) after laparoscopic extralevator abdominoperineal excision (ELAPE). This study aimed to evaluate the short-term outcomes of CPP after ELAPE and provide supporting evidence for the performance of CPP in laparoscopic ELAPE. METHODS Patients with rectal cancer who underwent ELAPE from January 2014 to April 2019 were retrospectively investigated. CPP was routinely performed unless it was not feasible. The main outcome was the difference in the occurrence of perineal hernia (PH), small bowel obstruction (SBO) and perineal wound complications between laparoscopic and open ELAPE, which were compared using Kaplan-Meier curves. RESULTS Of the 244 patients included, 104 received laparoscopic ELAPE, and 140 received open ELAPE. Patients in the laparoscopic group suffered a higher incidence of PH (11.5% (12/104) vs. 5.0% (7/140), p = 0.049), SBO (10.6% (11/104) vs. 7.9% (11/140), p = 0.433) and major perineal wound complications (12.5% (13/104) vs. 7.9% (11/140), p = 0.228) than those in the open group. Multivariate analysis showed that no-CPP was an independent risk factor for the occurrence of PH (p = 0.022, OR 3.436, 95% CI 1.199-9.848) and major perineal wound complications (p = 0.012, OR 3.683, 95% CI 1.337-10.146). CONCLUSION In this comparative cohort study with a risk of allocation bias, CPP was associated with a lower incidence of radiological PH and major perineal wound complications regardless of the surgical approach. Thus, we believe CPP could serve as an option L-ELAPE for the prevention of perineal complications. To further determine the impact of CPP on postoperative complications after ELAPE, a prospective multicentre study is needed.
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Affiliation(s)
- Yu Shen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Tinghan Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Hanjiang Zeng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wenjian Meng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China.
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Girsang BM, Elfira E. Utilization of “Perineal Wound Image Application” In Perineal Wound Digital Image Screening. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: A variety of serious conditions can affect the perineum, from infections that clear up on their own to conditions that are dangerous or add to the patient’s discomfort. Data at the level of each zone are an important factor for determining the area of wound healing. Injury investigations should include the identification of the injury, the calculation of the area of the injury which is generally important in determining treatment.
AIM: This study aims to present the findings of determining the characteristics of the perineal wound category and determining the area of the wound using MATLAB programming.
MATERIALS AND METHODS: The trial data in this study used 10 digital images with the development of 1000 trials and resulted in an accuracy rate of 86%. Digital image application is designed with 11 categories of perineal wounds that include assessment of wound color and characteristics.
RESULTS: The use of the application was carried out by 21 midwife health workers with the results of 81% of applications making it easier for officers to classify wounds, and 85.7% stated that the application could be a guide in making decisions about perineal wound care. Determination of wound categories and perineal wound area in this program proves the ease for health workers in planning appropriate care and treatment. This makes it very easy for users to do programming so that users are not too bothered by programming logic and focus more on the logic of solving problems on a hand.
CONCLUSION: The development of innovative perineal wound screening applications will provide convenience in practicality and efficiency of use in the future.
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