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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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Racine M, Meurette G, Ris F, Meyer J, Toso C, Liot E. Management of Squamous Cell Carcinomas of the Anal Canal and Anal Margin After Failure of Chemoradiotherapy Treatment: A Narrative Review. Cancers (Basel) 2025; 17:1511. [PMID: 40361438 PMCID: PMC12070889 DOI: 10.3390/cancers17091511] [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: 02/20/2025] [Revised: 04/17/2025] [Accepted: 04/23/2025] [Indexed: 05/15/2025] Open
Abstract
Anal squamous cell carcinoma (ASCC) is a rare malignancy with an increasing incidence despite advancements in treatment. The primary treatment for localized ASCC is radiochemotherapy (RCT), which achieves high rates of tumor regression in most cases, but up to 30% of patients experience recurrence or persistent disease. Salvage surgery, such as an abdominoperineal resection (APR), is often used for recurrent disease but is associated with significant morbidity and limited oncological outcomes. Patients with small T1 tumors may also benefit from primary local excision. For patients with metastatic or unresectable recurrent ASCC, chemotherapy, particularly carboplatin and paclitaxel, remains the standard treatment. New therapeutic strategies, including immune checkpoint inhibitors like pembrolizumab, are showing promise, particularly in PD-L1-positive tumors. Clinical trials have suggested that immunotherapy offers a potential alternative for patients for whom conventional treatments have failed, though the overall response rates remain modest. Re-radiation and intraoperative radiotherapy combined with salvage surgery may improve the outcomes for select patients, though the data are still limited. The management of recurrent or persistent ASCC requires a personalized approach, incorporating both established and emerging therapies to optimize patient outcomes. Further research is needed to refine these treatment strategies.
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Affiliation(s)
- Michaël Racine
- Visceral Surgery, Department of Surgery, Geneva University Hospital, 1205 Geneva, Switzerland
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Hirata S, Kanemitsu Y, Moritani K, Arikawa M, Kudose Y, Takamizawa Y, Inoue M, Tsukamoto S, Daiko H, Akazawa S. A pedicled anterolateral thigh flap decreased the risk of empty pelvis syndrome following total pelvic exenteration. Colorectal Dis 2025; 27:e17239. [PMID: 39545460 DOI: 10.1111/codi.17239] [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: 09/26/2023] [Revised: 05/05/2024] [Accepted: 10/14/2024] [Indexed: 11/17/2024]
Abstract
AIM Total pelvic exenteration (TPE) can be complicated by empty pelvis syndrome (EPS), and none of the currently available procedures completely mitigate this problem. The aim of this study was to evaluate the feasibility and effectiveness of a pedicled anterolateral thigh (p-ALT) flap for preventing EPS. METHOD All cases of TPE at the National Cancer Center Hospital in Tokyo between 2008 and 2022 were retrospectively reviewed. The main indication for TPE was colorectal cancer, with some other malignancies. Background factors, surgical outcomes and postoperative complications were compared between patients who underwent primary suture closure (the PC group) and those who underwent p-ALT flap reconstruction (the flap group). RESULTS A total of 114 patients underwent TPE during the study period. Twenty patients in whom a different procedure was performed or a different flap was used for reconstruction were excluded, leaving 94 for analysis (PC group, n = 54; flap group, n = 40). There was no significant between-group difference in patient characteristics. Severe pelvic abscess developed in 12 patients (22.2%) in the PC group and 2 (5%) in the flap group. Multivariable analysis identified a significantly lower risk of severe pelvic abscess in the p-ALT flap reconstruction (OR 0.07, 95% CI 0.01-0.58, p = 0.01). EPS-related readmissions were more common in the PC group [37.0% (20/54) vs. 25% (10/40)]. CONCLUSIONS The risk of severe pelvic abscesses and readmission for EPS was significantly lower after perineal reconstruction with a p-ALT flap. Perineal reconstruction with this flap is a feasible and effective method in TPE.
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Affiliation(s)
- Shintaro Hirata
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Konosuke Moritani
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Masaki Arikawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yozo Kudose
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuyuki Takamizawa
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Manabu Inoue
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Daiko
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Akazawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
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Asaad M, Mitchell D, Slovacek C, Hassan AM, Rajesh A, Liu J, Kapur S, Baumann D, Butler CE. Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction. Plast Reconstr Surg 2024; 154:1105-1114. [PMID: 38051145 DOI: 10.1097/prs.0000000000011233] [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: 12/07/2023]
Abstract
BACKGROUND The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. The authors aimed to evaluate outcomes of the VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction. METHODS The authors conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January of 2001 and March of 2021. Our primary outcome measure included recipient and donor surgical-site occurrences (SSOs). RESULTS The authors identified a total of 546 patients (55% women) with a mean age of 58 years and mean body mass index of 27 kg/m 2 . Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient SSOs occurred in 38% of patients, and donor SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients, and bulge developed in 6.4% of patients. The Cox proportional hazards regression model for hernia occurrence identified age, body mass index, tobacco use (hazard ratio, 2.03; 95% CI, 1.02 to 4.04), and use as an extended VRAM flap (hazard ratio, 2.13; 95% CI, 1.04 to 4.36). The use of mesh or component separation were not independent protective factors for hernia occurrence. CONCLUSIONS The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor-site hernia occurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Malke Asaad
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
| | - David Mitchell
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
- University of Texas, McGovern Medical School
| | - Cedar Slovacek
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
- University of Texas, McGovern Medical School
| | - Abbas M Hassan
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
| | - Aashish Rajesh
- Department of Surgery, University of Texas at San Antonio
| | - Jun Liu
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
| | - Sahil Kapur
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
| | - Donald Baumann
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
| | - Charles E Butler
- From the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center
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Shahzad F, Ray E. Pelvic and Perineal Reconstruction. Plast Reconstr Surg 2024; 154:803e-816e. [PMID: 39314105 PMCID: PMC11424020 DOI: 10.1097/prs.0000000000011137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction. SUMMARY Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap.
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Affiliation(s)
- Farooq Shahzad
- Plastic & Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Edward Ray
- Division of Plastic & Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles, USA
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Temperley HC, Shokuhi P, O'Sullivan NJ, Mac Curtain B, Waters C, Murray A, Buckley CE, O'Neill M, Mehigan B, McCormick PH, Kelly ME, Larkin JO. Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis. Ir J Med Sci 2024; 193:1721-1728. [PMID: 38532236 PMCID: PMC11294374 DOI: 10.1007/s11845-024-03651-3] [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: 09/23/2023] [Accepted: 01/05/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE/AIM Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. METHODS PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality. RESULTS Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49; CONCLUSION We highlight the advantage of VRAM flap closure over primary closure for perineal wounds following APR. However, tailoring operative strategy based on patient and disease factors remains important in optimising outcomes.
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Affiliation(s)
- Hugo C Temperley
- Department of Surgery, St. James's Hospital, Dublin, Ireland.
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.
| | - Poorya Shokuhi
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | | | - Caitlin Waters
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Alannah Murray
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Maeve O'Neill
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Brian Mehigan
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | | | - Michael E Kelly
- Department of Surgery, St. James's Hospital, Dublin, Ireland
- Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland
| | - John O Larkin
- Department of Surgery, St. James's Hospital, Dublin, Ireland
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Zaussinger M, Pommer G, Freller K, Schmidt M, Huemer GM. Bilateral Superior Gluteal Artery Perforator (SGAP) Flap: Modified Concept in Perineal Reconstruction. J Clin Med 2024; 13:3825. [PMID: 38999391 PMCID: PMC11242694 DOI: 10.3390/jcm13133825] [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: 05/30/2024] [Revised: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52-76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7-9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.
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Affiliation(s)
- Maximilian Zaussinger
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
- Doctoral Degree Program in Medical Science, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Gabriele Pommer
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
| | - Katrin Freller
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
| | - Manfred Schmidt
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
| | - Georg M. Huemer
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
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Boccara D, Lefevre JH, Serror K, Chatelain S, Dutot MC, Kaplan J, Mimoun M, Chaouat M, Levy S. Short- and long-term morbidity after Taylor flap (oblique rectus abdominis flap) for perineal reconstruction after abdominoperineal resection: A single-center series of 140 patients. J Plast Reconstr Aesthet Surg 2024; 93:163-169. [PMID: 38696870 DOI: 10.1016/j.bjps.2024.04.037] [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: 08/07/2023] [Revised: 02/17/2024] [Accepted: 04/11/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Abdominoperineal resection (APR) leads to a substantial loss of tissue and a high rate of complications. The Taylor flap is a musculocutaneous flap used in reconstruction after APR. OBJECTIVES We aimed to analyze the short and long-term morbidity of reconstruction with a Taylor flap (oblique rectus abdominis flap) after APR and to identify the risk factors for postoperative complications. METHODS We retrospectively included all patients who had undergone APR with immediate reconstruction with a Taylor flap in our department between July 2000 and June 2018. Demographics, oncological data, treatment, and short- and long-term morbidity were reviewed. RESULTS Among the 140 patients included, we identified early minor complications in 42 patients (30%) and 14 early major complications (10%). Total necrosis of the flap requiring its removal occurred in four patients (2.8%). Eleven patients (7.9%) presented with a midline incision hernia, and seven (5%) presented with a subcostal incision hernia. No perineal hernia was found. No risk factors for the complications were identified. CONCLUSION The Taylor flap is a safe procedure with few complications and limited donor site morbidity. Moreover, it prevents perineal hernias. These results confirm that the Taylor flap is a well-suited procedure for reconstruction after APR.
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Affiliation(s)
- David Boccara
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France.
| | - Jeremie H Lefevre
- Department of General Surgery, Saint Antoine Hospital, Paris, France
| | - Kevin Serror
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | - Sarah Chatelain
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | | | - Jeremy Kaplan
- Division of Gastroenterology, Kingman Regional Medical Center, Kingman, AR, USA
| | - Maurice Mimoun
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | - Marc Chaouat
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
| | - Samuel Levy
- Department of Plastic Surgery, Saint Louis Hospital, Paris, France
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Peng Y, Xiong S, Ding Y, Xie L, Wang Y, Mei Y, Liu W, Deng T. The effect of omentoplasty in various surgical operations: systematic review and meta-analysis. Int J Surg 2024; 110:3778-3794. [PMID: 38446845 PMCID: PMC11175753 DOI: 10.1097/js9.0000000000001240] [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: 12/13/2023] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Omentoplasty is commonly used in various surgeries. However, its effectiveness is unsure due to lack of convincing data and research. To clarify the impact of omentoplasty on postoperative complications of various procedures, this systematic review and meta-analysis was performed. METHODS A systematic review of published literatures from four databases: PubMed, Web of Science, Cochrane Library, and Embase before 14 July 2022. The authors primarily included publications on five major surgical operations performed in conjunction with omentoplasty: thoracic surgery, esophageal surgery, gastrointestinal surgery, pelvi-perineal surgery, and liver surgery. The protocol was registered in PROSPERO. RESULTS This review included 25 273 patients from 91 studies ( n =9670 underwent omentoplasty). Omentoplasty was associated with a lower risk of overall complications particularly in gastrointestinal [relative risk (RR) 0.53; 95% CI: 0.39-0.72] and liver surgery (RR 0.54; 95% CI: 0.39-0.74). Omentoplasty reduced the risk of postoperative infection in thoracic (RR 0.38; 95% CI: 0.18-0.78) and liver surgery (RR 0.39; 95% CI: 0.29-0.52). In patients undergoing esophageal (RR 0.89; 95% CI: 0.80-0.99) and gastrointestinal (RR 0.28; 95% CI: 0.23-0.34) surgery with a BMI greater than 25, omentoplasty is significantly associated with a reduced risk of overall complications compared to patients with normal BMI. No significant differences were found in pelvi-perineal surgery, except infection in patients whose BMI ranged from 25 kg/m 2 to 29.9 kg/m 2 (RR 1.25; 95% CI: 1.04-1.50) and anastomotic leakage in patients aged over 60 (RR 0.59; 95% CI: 0.39-0.91). CONCLUSION Omentoplasty can effectively prevent postoperative infection. It is associated with a lower incidence of multiple postoperative complications in gastrointestinal and liver surgery.
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Affiliation(s)
- Yaqi Peng
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
| | - Shan Xiong
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
| | - Yujin Ding
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
| | - Limin Xie
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
| | - Yihang Wang
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
| | - Ying Mei
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
| | - Wei Liu
- Department of Biliopancreatic Surgery and Bariatric Surgery
| | - Tuo Deng
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology
- Key Laboratory of Diabetes Immunology, Ministry of Education, Metabolic Syndrome Research Center
- Clinical Immunology Center, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
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10
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [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: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Kreisel SI, Sparenberg S, Sharabiany S, Hompes R, Lapid O, van der Horst CMAM, Musters GD, Tanis PJ. Gluteal Fasciocutaneous Flap Reconstruction After Salvage Surgery for Pelvic Sepsis. Dis Colon Rectum 2023; 66:1570-1577. [PMID: 36940299 DOI: 10.1097/dcr.0000000000002648] [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: 03/22/2023]
Abstract
BACKGROUND Chronic pelvic sepsis mostly originates from complicated pelvic surgery and failed interventions. This is a challenging condition that often requires extensive salvage surgery consisting of complete debridement with source control and filling of the dead space with well-vascularized tissue. OBJECTIVE This study aimed to describe the outcomes of gluteal fasciocutaneous flaps for the treatment of secondary pelvic sepsis. DESIGN Retrospective single-center cohort study. SETTINGS Tertiary referral center. PATIENTS Patients who underwent salvage surgery for secondary pelvic sepsis between 2012 and 2020 using a gluteal flap were included in this study. MAIN OUTCOME MEASURES Percentage of complete wound healing. RESULTS In total, 27 patients were included, of whom 22 underwent index rectal resection for cancer and 21 had undergone (chemo)radiotherapy. A median of 3 (interquartile range, 1-5) surgical and 1 (interquartile range, 1-4) radiological interventions preceded salvage surgery during a median period of 62 (interquartile range, 20-124) months. Salvage surgery included partial sacrectomy in 20 patients. The gluteal flap consisted of a V-Y flap in 16 patients, superior gluteal artery perforator flap in 8 patients, and a gluteal turnover flap in 3 patients. Median hospital stay was 9 (interquartile range, 6-18) days. During a median follow-up of 18 (interquartile range, 6-34) months, wound complications occurred in 41%, with a reintervention rate of 30%. The median time to wound healing was 69 (interquartile range, 33-154) days, with a complete healing rate of 89% at the end of follow-up. LIMITATIONS Retrospective design and heterogeneous patient population. CONCLUSIONS In patients undergoing major salvage surgery for chronic pelvic sepsis, the use of gluteal fasciocutaneous flaps is a promising solution because of the high success rate, limited risks, and relatively simple technique. See Video Abstract at http://links.lww.com/DCR/C160 . RECONSTRUCCIN CON COLGAJO FASCIOCUTNEO GLTEO DESPUS DE UNA CIRUGA DE RESCATE POR SEPSIS PLVICA ANTECEDENTES:La sepsis pélvica crónica esta causada principalmente por cirugías pélvicas complicadas e intervenciones fallidas. Esta es una condición desafiante que a menudo requiere una cirugía de rescate extensa que consiste en un desbridamiento completo controlando el orígen infeccioso y rellenando el espacio muerto con tejido bien vascularizado, como por ejemplo un colgajo de tejido autólogo. La pared abdominal (colgajo de recto abdominal) o la pierna (colgajo de gracilis) se utilizan principalmente como sitios donantes para esta indicación, mientras que los colgajos glúteos pueden ser alternativas atractivas.OBJETIVO:Describir los resultados de los colgajos fasciocutáneos glúteos en el tratamiento de la sepsis pélvica secundaria.DISEÑO:Estudio de cohortes retrospectivo en un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Todos aquellos que se sometieron a cirugía de rescate por sepsis pélvica secundaria entre 2012 y 2020 utilizando un colgajo fasciocutáneo glúteo.PRINCIPALES MEDIDAS DE RESULTADO:El porcentaje de cicatrización completa de la herida.RESULTADOS:En total, se incluyeron 27 pacientes, de los cuales 22 fueron sometidos a resección rectal por cáncer indicada y 21 pacientes que habían recibido (quimio)radioterapia. Una mediana de tres (RIC 1-5) intervenciones quirúrgicas y una (RIC 1-4) intervenciones radiológicas precedieron a la cirugía de rescate durante una mediana de 62 (RIC 20-124) meses.La cirugía de rescate incluyó una resección parcial del sacro en 20 pacientes. El colgajo fasciocutáneo glúteo consistió en la confección de un colgajo en V-Y en 16 pacientes, un colgajo incluyendo la perforante de la arteria glútea superior en 8 y un colgajo de rotación de músculo glúteo en 3 pacientes.La mediana de estancia hospitalaria fue de nueve (RIC 6-18) días. Durante una mediana de seguimiento de 18 (IQR 6-34) meses, se produjeron complicaciones de la herida en el 41%, con una tasa de reintervención del 30%.La mediana de tiempo hasta la cicatrización de la herida fue de 69 (IQR 33-154) días con una tasa de cicatrización completa del 89 % al final del seguimiento cicatricial.LIMITACIONES:Diseño retrospectivo y población heterogénea de pacientes.CONCLUSIONES:En pacientes sometidos a cirugía mayor de rescate por sepsis pélvica crónica, el uso de colgajos fasciocutáneos glúteos es una solución prometedora debido a la alta tasa de éxito, los riesgos limitados y la técnica relativamente simple. Video Resumen en http://links.lww.com/DCR/C160 . (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Saskia I Kreisel
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Sparenberg
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Oren Lapid
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Chantal M A M van der Horst
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
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12
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Liu J, Fu C, Chen Z, Li G. Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis. Int Wound J 2023; 20:3963-3973. [PMID: 37539486 PMCID: PMC10681467 DOI: 10.1111/iwj.14284] [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: 05/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 08/05/2023] Open
Abstract
A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.
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Affiliation(s)
- Jiang Liu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Chao Fu
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Zhiliang Chen
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
| | - Gang Li
- Department of Anorectal SurgeryShaoxing People's HospitalZhejiangChina
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13
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Gambardella C, Mongardini FM, Karpathiotakis M, Lucido FS, Pizza F, Tolone S, Parisi S, Nesta G, Brusciano L, Gambardella A, Docimo L, Mongardini M. Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study. Cancers (Basel) 2023; 15:2725. [PMID: 37345062 PMCID: PMC10216202 DOI: 10.3390/cancers15102725] [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: 04/15/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure. METHODS From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152). CONCLUSIONS In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.
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Affiliation(s)
- Claudio Gambardella
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Menelaos Karpathiotakis
- Division of General Surgery, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.K.); (M.M.)
| | - Francesco Saverio Lucido
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Francesco Pizza
- Department of Surgery, Hospital ‘A. Rizzoli’, Lacco Ameno, 80076 Naples, Italy;
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Simona Parisi
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Giusiana Nesta
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Luigi Brusciano
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Antonio Gambardella
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
| | - Ludovico Docimo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Massimo Mongardini
- Division of General Surgery, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.K.); (M.M.)
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Cataneo JL, Mathis SA, Faqihi S, Valle DDD, Perez-Tamayo AM, Mellgren AF, Alkureishi LWT, GanttJr G. Comparison of Perineal Closure Techniques after Abdominoperineal Resections for Carcinoma of the Anus. Am Surg 2023; 89:238-246. [PMID: 36637044 DOI: 10.1177/00031348221146936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Perineal reconstruction following salvage APR's for squamous cell carcinoma of the anus (SCCA) are scant with conflicting results from large and single center studies. We analyzed these techniques taking into account sociodemographic and oncologic variables. METHODS This is a retrospective cohort study from 2016-2019 using a targeted ACS/NSQIP database stratified into primary closure (PC), abdominal myocutaneous (AM), lower extremity (LE), and omental pedicled (OP) flaps. We analyzed major and wound complications through univariate and multivariate regression analysis. RESULTS A total of 766 patients were analyzed, 512 (67%) had PC, 196 (25%) AM, 36 (5%) OP and 22 (3%) LE. Rates of chemotherapy and radiation within 90 days were similar between the groups. Having 2 or more additional organs resected was more common for the AM group (AM 4.1%, PC 1.6%, OP 3.3%, LE 0%). Overall, major complication rate was 41% (n = 324). Primary closure had 35.0%, OP 47.2%, AM 52.6%, and LE 45.5%. Wound complication rate was highest in AM with 11.7%, followed by OP 8.3%, PC 5.9%, and LE 0%. The multivariate regression analysis demonstrated none of the closure techniques to be associated with increasing or decreasing the probability of having a major or wound complication. Morbidity probability was the sole predictor of major complication (OR 1.07, 95% CI 1.04-1.1). CONCLUSIONS Myocutaneous and omental flaps are associated with comparable wound and major complications when taking into account the baseline, oncologic and perioperative variables that drive the clinical decision making when selecting a perineal reconstruction.
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Affiliation(s)
- Jose L Cataneo
- 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Sydney A Mathis
- 14405University of Illinois Chicago, College of Medicine at Rockford, Rockford, IL, USA
| | - Sabreen Faqihi
- 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Diana D Del Valle
- 1857Harvard University T H Chan School of Public Health, Boston, MA, USA
| | | | - Anders F Mellgren
- Division of Colon & Rectal Surgery, 14681University of Illinois Chicago, Chicago, IL, USA
| | - Lee W T Alkureishi
- Division of Plastic Reconstructive and Cosmetic Surgery, 14681University of Illinois Chicago, Chicago, IL, USA
| | - Gerald GanttJr
- Division of Colon & Rectal Surgery, 14681University of Illinois Chicago, Chicago, IL, USA
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15
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Cataneo JL, Mathis SA, Del Valle DD, Perez-Tamayo AM, Mellgren AF, Gantt G, Alkureishi LWT. Outcomes of perineal wound closure techniques after abdominoperineal resections in rectal cancer: an NSQIP propensity score matched study. J Plast Surg Hand Surg 2023; 57:399-407. [PMID: 36433927 DOI: 10.1080/2000656x.2022.2144333] [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] [Indexed: 11/27/2022]
Abstract
Perineal defects following abdominoperineal resections (APRs) for rectal cancer may require myocutaneous or omental flaps depending upon anatomic, clinical and oncologic variables. However, studies comparing their efficacy have shown contradictory results. We aim to compare postoperative complication rates of APR closure techniques in rectal cancer using propensity score-matching. The American College of Surgeons Proctectomy Targeted Data File was queried from 2016 to 2019. The study population was defined using CPT and ICD-10 codes for patients with rectal cancer undergoing APR, stratified by repair technique. Perioperative demographic and oncologic variables were controlled for by propensity-score matching. Multivariate logistic regression analysis was performed for wound and major complications (MCs). Of the 3291 patients included in the study, 85% underwent primary closure (PC), 8.3% rectus abdominis myocutaneous (RAM) flap, 4.9% pedicled omental flap with PC, and 1.9% lower extremity (LE) flap repair. Primary closure rates were significantly higher for patients with stage T1 and T2 tumors (p < 0.001). RAM and LE flaps were most used with multi-organ resections, 24% and 25%, respectively (p < 0.001). Similarly, cases with T4 tumors used these flaps more frequently, 30% and 40%, respectively (p < 0.001). After propensity score matching for comorbidities and oncologic variables, there was no significant difference in 30-day postoperative wound or MC rates between perineal closure techniques. The complication rates of the different closure techniques are comparable when tumor stage is considered. Therefore, tumor staging and concurrent procedures should guide clinical decision making regarding the appropriate use of each technique.
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Affiliation(s)
- Jose L Cataneo
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sydney A Mathis
- College of Medicine, University of Illinois at Chicago, Rockford, IL, USA
| | - Diana D Del Valle
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alejandra M Perez-Tamayo
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Anders F Mellgren
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Gerald Gantt
- Department of Surgery, Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Lee W T Alkureishi
- Department of Surgery, Division of Plastic Reconstructive and Cosmetic Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Fascia Lata Grafting Combined with Gluteal Flaps for Pelvic Floor Reconstruction after Oncologic Resection. Plast Reconstr Surg Glob Open 2022; 10:e4528. [PMID: 36246078 PMCID: PMC9556018 DOI: 10.1097/gox.0000000000004528] [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: 06/07/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
Abstract
Although recent methods of pelvic reconstruction using myocutaneous flaps have reduced postoperative morbidities' including pelvic abscess, the complication rates are still high due to the presence of a large dead cavity and poorly vascularized tissues secondary to preoperative chemoradiation therapy. We aimed to evaluate the usefulness and benefit of fascia lata autografting for pelvic floor reconstruction as a supplemental procedure for gluteal flap closure of perineal wounds. Methods Our retrospective study included 144 consecutive patients who underwent rectal cancer resection with or without pelvic reconstruction, from 2010 to 2020. For reconstruction, fascia lata autografts were harvested from the thigh and affixed to the pelvic floor. The perineal wound was closed using gluteal advancement flaps. Results The study included 33 reconstructed and 111 nonreconstructed patients (average age: 69.5 years). The reconstructed group was more likely to have undergone preoperative chemotherapy (81.8% versus 40.5%, P < 0.001) and radiotherapy (78.8% versus 48.6%, P = 0.002), compared with the nonreconstructed group. Additionally, the reconstructed group underwent fewer abdominoperineal resections (63.6% versus 94.6%, P < 0.001) and more pelvic exenterations (36.4% versus 5.4%). The mean size of fascia lata autografts was 8.3 × 5.9 cm. There were significant differences between the reconstructed and nonreconstructed groups, in the incidences of complications (15.2% versus 33.3%, P = 0.044) and pelvic abscess (3.0% versus 16.2%, P = 0.049). Conclusion Combination of fascia lata autografts and gluteal flaps is considered an effective method of pelvic reconstruction for its low incidence of complications and stable outcomes.
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Meuli JN, Hubner M, Martineau J, Oranges CM, Guillier D, Raffoul W, di Summa PG. Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: A retrospective cohort study. J Surg Oncol 2022; 127:40-47. [PMID: 36112361 PMCID: PMC10087003 DOI: 10.1002/jso.27092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Large and deep perineal defects following abdominal perineal resection (APR) are a challenge for reconstructive surgeons. Even if generally performed for oncological reasons, APR can be indicated as well in extended infection-related debridement for Hidradenitis suppurativa, Fournier's gangrene, or Crohn's disease. We aimed to compare the outcomes of two groups of patients with different indications for APR (infectious vs. oncological) after pedicled anterolateral thigh (ALT) flap coverage RESULTS: Forty-four consecutive pedicled ALT flap used for coverage after APR in 40 patients were analyzed. 26 patients (65%) underwent APR for oncological reasons and 14 patients (35%) for infectious reasons. The overall postoperative complications rate was significantly higher for infectious cases (76.5% vs. 40.7%, p = 0.0304). Major complications occurred in 52.9% of infectious cases versus 11.1% of oncological cases (p = 0.0045). Obesity and infectious etiology were independent risk factors for overall and major complications, respectively. CONCLUSION Patients undergoing APR for acute or chronic infections had significantly more overall and major complications than patients having oncological APR. Modified care might be considered, especially in obese patients, in terms of surgical debridement, antibiotic treatment modalities, and postoperative management.
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Affiliation(s)
- Joachim N. Meuli
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Martin Hubner
- Department of Visceral Surgery Lausanne University Hospital Lausanne Switzerland
| | - Jérôme Martineau
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Carlo M. Oranges
- Department of Plastic, Reconstructive and Aesthetic Surgery Geneva University Hospitals Geneve Switzerland
| | - David Guillier
- Unit of Facial, Plastic, Reconstructive, Aesthetic and Hand Surgery CHU Dijon Dijon France
| | - Wassim Raffoul
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
| | - Pietro G. di Summa
- Department of Plastic and Hand Surgery Lausanne University Hospital Lausanne Switzerland
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Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis. Cancers (Basel) 2022; 14:cancers14174300. [PMID: 36077834 PMCID: PMC9454697 DOI: 10.3390/cancers14174300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The rate of perineal complications after abdominoperineal reconstruction for the treatment of cancers ranges from 25% to 60% in the literature. It is well-established in current literature that direct closure has a higher complication rate than closure with a flap. Several reconstructive options have been proposed to fill the dead space with well-vascularized tissue. Every surgeon would like to be comfortable in selecting which flap has superiority in terms of surgical outcome. In the absence of a meta-analysis on the subject due to the scarcity of RCT and comparative studies, we used a proportional meta-analysis to analyze the surgical outcomes after reconstruction with either VRAM flap or gracilis flap following oncologic resection of the vulvo-perineal region. Abstract Pelvic exenteration and abdominoperineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy with high morbidity due to large pelvic defects. Flaps can help provide healthy, well-vascularized, non-irradiated tissues to fill pelvic dead space. We conducted a proportional meta-analysis to compare surgical outcomes of vertical rectus abdominus myocutaneous flap (VRAM) vs. gracilis flap for vulvo-perineal reconstruction following oncologic resection. A comprehensive literature search was conducted in the MEDLINE, PubMed, Embase, Google Scholar, and Cochrane Library databases. Proportional meta-analysis was performed to compare the surgical outcomes of using VRAM or gracilis flaps. Our review yielded 16 eligible studies. The pooled resolution rate of overall donor site complications for VRAM flap (pooled proportion = 0.576 [95% CI 0.387, 0.754]) was significantly higher than the pooled rate of overall donor site complications of gracilis flap (pooled proportion = 0.160 [95% CI 0.058, 0.295]). Partial and total flap necrosis were similar in both groups. There was no statistically significant difference between minor and major complications for both flaps. Both flaps can be used safely for vulvo-perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.
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Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy. Ann Plast Surg 2022; 89:306-311. [PMID: 35993686 DOI: 10.1097/sap.0000000000003258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.
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Pérez-García A, García-Granero Á, Thione A, Frasson M, Sánchez-García A, Salmerón-González E, Simón E, Domingo S, García-Granero E. Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection. J Surg Oncol 2022; 126:1383-1388. [PMID: 36003058 DOI: 10.1002/jso.27068] [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: 02/06/2022] [Revised: 07/14/2022] [Accepted: 08/07/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection. METHODS A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space. RESULTS Forty-four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence. CONCLUSIONS The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.
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Affiliation(s)
- Alberto Pérez-García
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | | | - Alessandro Thione
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | - Matteo Frasson
- Department of General Surgery, La Fe University Hospital, Valencia, Spain
| | | | | | - Eduardo Simón
- Department of Plastic Surgery and Burns, La Fe University Hospital, Valencia, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology, La Fe University Hospital, Valencia, Spain
| | - E García-Granero
- Department of General Surgery, La Fe University Hospital, Valencia, Spain
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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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22
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Zhang H, Li Z, Li J, Zhu L, Ibrahim Y. The Pedicled Flap of Adductor Longus, a New Technique for Inguinal Reconstruction. Front Surg 2022; 8:639893. [PMID: 34977135 PMCID: PMC8717469 DOI: 10.3389/fsurg.2021.639893] [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: 01/07/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Reconstruction surgeries of the inguinal area pose a challenge for oncological and orthopedic surgeons, especially after radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both. Although numerous surgical procedures have been reported, there is no report about a pedicle adductor longus flap method. The aim of this work is to show our experience about inguinal reconstruction with pedicled adductor longus flap and associated outcomes. Patients and Methods: A retrospective study of 16 patients with localized inguinal region interventions and reconstructed by adductor longus flap from March 2016 to July 2020. Patients' average age was 60.0 years (range = 38-79 years) and had postoperative follow-up of 10 months (ranging 2-19 months). All patients had unilateral inguinal region involvement-seven cases on the left and nine cases on the right. The patients' clinical course, operative course, and postoperative follow-up data were evaluated. Results: All 16 patients recovered well post-operatively and did not require any re-intervention. Four patients experienced negligible discomfort around the groin area. Five patients experienced a minor strength deficit in thigh adduction compared with that of preoperative strength in the same or contralateral leg. The aforementioned complications resolved during the postoperative course and had no functional impact on their activity of daily living. All adductor longus flaps survived, completely filled the inguinal dead space, and wounds healed uneventfully within 3 weeks except for three patients who suffered delayed wound healing for more than 4 weeks. Other common complications such as infection, seroma, or wound dehiscence were not encountered in this series. Conclusion: The adductor longus flap is a reliable alternative method for inguinal region reconstruction following radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both.
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Affiliation(s)
- Hong Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Zhenfeng Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Jianmin Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Lei Zhu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Yakubu Ibrahim
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
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Oncologic and Functional Outcomes of Pelvic Perineal Reconstruction by Perineal Colostomy and Malone Procedure After Abdominoperineal Resection. Dis Colon Rectum 2021; 64:1501-1510. [PMID: 34747916 DOI: 10.1097/dcr.0000000000001941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Abdominoperineal resection is the standard curative surgical technique for locally advanced adenocarcinoma of the lower rectum and squamous cell carcinoma of the anal canal after chemoradiotherapy. However, it requires a definitive abdominal colostomy that modifies the body appearance. OBJECTIVE The study aim was to evaluate the combination of abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema. DESIGN This was a retrospective study. SETTINGS The study was conducted at the Toulouse Hospital Digestive Surgery Department. PATIENTS All of the patients with advanced adenocarcinoma or squamous cell carcinoma who underwent abdominoperineal resection with perineal colostomy reconstruction and Malone antegrade continence enema (n = 80) between December 1999 and December 2016 were included. MAIN OUTCOME MEASURES The main outcome was the 5-year overall survival rate. RESULTS The 5-year overall survival was 74.89% (95% CI, 62.91%-83.50%), and the median recurrence-free survival was 107.6 months (95% CI, 65.1-198.1 mo). The median follow-up was 91.0 months (95% CI, 70.4-116.6 mo). R0 resection was obtained in 64 patients (80.0%). The median Cleveland Clinic Incontinence Score (to assess the functional outcomes) was 9.0 (interquartile range, 1.0-18.0), and it was lower in patients with advanced adenocarcinoma than with squamous cell carcinoma (7.0 (interquartile range, 2.0-18.0) vs 11.0 (interquartile range, 1.0-17.0); p = 0.01). Eleven patients (13.8%) reported perineal stains during the night, and 19 patients (23.8%) needed drugs to reduce colon motility. The rate of severe complications (Clavien-Dindo >II) was 11.7% (n = 9). Definitive colostomy was performed in 15 patients (18.8%). LIMITATIONS This retrospective study included a small number of patients from a single center. Moreover, the functional outcome was tested with self-report questionnaires (risk of response bias). CONCLUSIONS This study suggests that abdominoperineal resection associated with perineal reconstruction by perineal colostomy and Malone antegrade continence enema is safe and may improve patient quality of life. See Video Abstract at http://links.lww.com/DCR/B629. RESULTADOS ONCOLGICOS Y FUNCIONALES DE LA RECONSTRUCCIN PLVIPERINEAL MEDIANTE COLOSTOMA PERINEAL Y PROCEDIMIENTO DE MALONE DESPUS DE LA RESECCIN ABDOMINOPERINEAL ANTECEDENTES:La resección abdominoperineal es la técnica quirúrgica curativa estándar para el tratamiento del adenocarcinoma localmente avanzado del recto inferior y el carcinoma a células escamosas del canal anal, después de radio-quimioterapia. Sin embargo, requiere una colostomía abdominal definitiva que modifica la apariencia corporal.OBJETIVO:El propósito del presente estudio fue el evaluar la combinación de la resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone.DISEÑO:Estudio retrospectivo.AJUSTES:Servicio de Cirugía Digestiva del Hospital de Toulouse, Francia.PACIENTES:Se incluyeron todos los pacientes con adenocarcinoma avanzado o carcinoma de células escamosas que se sometieron a resección abdominoperineal con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone (n = 80) entre diciembre de 1999 y diciembre de 2016.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue la tasa de sobrevida global a 5 años.RESULTADOS:La sobrevida global a 5 años fue de 74,89% (IC del 95%, 62,91 a 83,50) y la mediana de supervivencia libre de recurrencia fue de 107,6 meses (IC del 95%, 65,1 a 198,1). La mediana de seguimiento fue de 91,0 meses (IC del 95%, 70,4-116,6). La resección R0 se obtuvo en 64 pacientes (80,0%). La mediana de puntuación de la escala de incontinencia de la Cleveland Clinic (para evaluar los resultados funcionales) fue de 9,0 [1,0; 18,0], y fue menor en pacientes con adenocarcinoma avanzado que con carcinoma de células escamosas (7,0 [2,0; 18,0] versus 11,0 [1,0; 17,0]; p = 0,01). Once pacientes (13,8%) refirieron manchado perineal nocurno y 19 pacientes (23,8%) necesitaron fármacos para reducir la motilidad del colon. La tasa de complicaciones graves (Clavien-Dindo > II) fue del 11,7% (n = 9). Se realizó colostomía definitiva en 15 (18,8%) pacientes.LIMITACIONES:Este estudio retrospectivo incluyó un pequeño número de pacientes y de un solo centro. Además, el resultado funcional se probó con cuestionarios de autoinforme (riesgo de sesgo de respuesta).CONCLUSIONES:Este estudio sugiere que la resección abdominoperineal asociada con la confección de una colostomía perineal asociada a enemas de continencia anterógrada según Malone es segura y puede mejorar la calidad de vida de los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B629.
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Assi H, Persson A, Palmquist I, Öberg M, Buchwald P, Lydrup ML. Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study. Eur J Surg Oncol 2021; 48:1161-1166. [PMID: 34794841 DOI: 10.1016/j.ejso.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. METHOD This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. RESULTS One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. CONCLUSION bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.
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Affiliation(s)
- Hanin Assi
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Anna Persson
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Ingrid Palmquist
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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25
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Bernuth S, Jakubietz M, Isbert C, Reibetanz J, Meffert R, Jakubietz R, Schmidt K. Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer. Technol Health Care 2021; 30:815-825. [PMID: 34744033 DOI: 10.3233/thc-213021] [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: 11/15/2022]
Abstract
BACKGROUND Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. OBJECTIVE Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. METHODS 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. RESULTS Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. CONCLUSION The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.
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Affiliation(s)
- Silvia Bernuth
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Michael Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Christoph Isbert
- Department of General, Visceral and Coloproctological Surgery, Amalie Sieveking Hospital Hamburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Germany
| | - Rainer Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Rafael Jakubietz
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
| | - Karsten Schmidt
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Germany
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Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice. J Pers Med 2021; 11:jpm11111076. [PMID: 34834428 PMCID: PMC8620180 DOI: 10.3390/jpm11111076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 12/04/2022] Open
Abstract
Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.
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Stein MJ, Karir A, Hanson MN, Cavale N, Almoudaris AM, Voineskos S. Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons. J Reconstr Microsurg 2021; 38:89-95. [PMID: 34187060 DOI: 10.1055/s-0041-1729750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs). METHODS Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management. RESULTS Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%). CONCLUSION A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.
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Affiliation(s)
- Michael J Stein
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Canada
| | - Aneesh Karir
- Division of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, Canada
| | - Melissa N Hanson
- Division of General Surgery, McGill University, Montreal, Canada
| | - Naveen Cavale
- Division of Plastic and Reconstructive Surgery, Kings College, London, United Kingdom
| | - Alex M Almoudaris
- Division of General Surgery, University College Hospital, London, United Kingdom
| | - Sophocles Voineskos
- Division of Plastic and Reconstructive Surgery, McMaster University, Hamilton, Ontario, Canada
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Lasso JM, Pinilla C, Vasquez W, Asencio JM. The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction. Ann Plast Surg 2021; 86:688-694. [PMID: 33346550 DOI: 10.1097/sap.0000000000002571] [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: 11/27/2022]
Abstract
INTRODUCTION Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.
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Affiliation(s)
- Jose M Lasso
- From the Department of Plastic and Reconstructive Surgery
| | - Carmen Pinilla
- From the Department of Plastic and Reconstructive Surgery
| | - Wenceslao Vasquez
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - J M Asencio
- Department of General Surgery, Hospital Gregorio Marañón, Madrid, Spain
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Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods. Plast Reconstr Surg 2021; 147:1420-1435. [PMID: 33973948 DOI: 10.1097/prs.0000000000007976] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. METHODS A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. RESULTS The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. CONCLUSIONS Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.
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Baloch N, Nordenvall C, Johansson H, Nygren J, Nilsson PJ. Perineal healing following salvage surgery for anal cancer. Colorectal Dis 2021; 23:1102-1108. [PMID: 33336448 PMCID: PMC8246882 DOI: 10.1111/codi.15496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 01/13/2023]
Abstract
AIM Approximately 25% of anal cancer patients undergo abdominoperineal excision or more extensive surgery. Following surgery, a high perineal complication rate has been reported. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal interventional programme introduced to mitigate the risk of complications. This study aims to describe perineal healing in relation to ERAS compliance, type of resection and method of perineal reconstruction in patients with anal cancer after salvage surgery. METHOD This is a retrospective cohort study including all patients undergoing abdominal surgery for squamous cell anal cancer in Stockholm between January 2005 and December 2015. Data collection was from registers supplemented by chart review. All patients were followed until death or 1 year after surgery. The associations between ERAS compliance, patient and treatment characteristics and perineal wound healing were evaluated using logistic regression. RESULTS In total, 101 patients (67 women) were included, of whom 72 were ERAS compliant. Of patients alive, healing after surgery occurred in 61/98 and 84/89 at 3 months and 1 year, respectively. Perineal healing at 3 months was statistically significantly associated with younger age and type of perineal reconstruction (in favour of vertical rectus abdominis myocutaneous flap). No associations were observed at 1 year but almost all wounds were healed. CONCLUSION Age and type of perineal reconstruction appear to be significantly associated with improved healing at 3 months whereas compliance to an ERAS protocol and type of resection do not. Nearly all patients had a fully healed perineal wound 1 year after surgery for anal cancer.
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Affiliation(s)
- Naseer Baloch
- Department of Pelvic CancerDivision of ColoproctologyKarolinska University HospitalStockholmSweden,Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Caroline Nordenvall
- Department of Pelvic CancerDivision of ColoproctologyKarolinska University HospitalStockholmSweden,Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Hemming Johansson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
| | - Jonas Nygren
- Department of SurgeryErsta HospitalStockholmSweden,Department of Clinical Sciences at Danderyds HospitalKarolinska InstitutetStockholmSweden
| | - Per J. Nilsson
- Department of Pelvic CancerDivision of ColoproctologyKarolinska University HospitalStockholmSweden,Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
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Buscail E, Canivet C, Shourick J, Chantalat E, Carrere N, Duffas JP, Philis A, Berard E, Buscail L, Ghouti L, Chaput B. Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040721. [PMID: 33578769 PMCID: PMC7916499 DOI: 10.3390/cancers13040721] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C. Abstract Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
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Affiliation(s)
- Etienne Buscail
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
- INSERM, U1220, Digestive Health Research Institute (IRSD), University of Toulouse, 31100 Toulouse, France
| | - Cindy Canivet
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
- Department of Gastroenterology and Pancreatology, Toulouse University Hospital, 31100 Toulouse, France
| | - Jason Shourick
- Department of Epidemiology and Public Health, UMR 1027 INSERM, Toulouse University Hospital, University of Toulouse, 31100 Toulouse, France; (J.S.); (E.B.)
| | - Elodie Chantalat
- Department of Surgery, Oncopole, INSERM-UPS UMR U1048, Institute of Metabolic and Cardiovascular Diseases, University of Toulouse, 31100 Toulouse, France;
| | - Nicolas Carrere
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Jean-Pierre Duffas
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Antoine Philis
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Emilie Berard
- Department of Epidemiology and Public Health, UMR 1027 INSERM, Toulouse University Hospital, University of Toulouse, 31100 Toulouse, France; (J.S.); (E.B.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Toulouse University Hospital, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-61-32-30-55; Fax: +33-5-61-32-22-29
| | - Laurent Ghouti
- Department of Digestive Surgery, Toulouse University Hospital, 31100 Toulouse, France; (E.B.); (C.C.); (N.C.); (J.-P.D.); (A.P.); (L.G.)
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Toulouse University Hospital, 31100 Toulouse, France;
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Yang Y, Yu L, Wang M, Mu Y, Li J, Shang F, Wu X, Liu T, Shi J. A new surgical approach of direct perineal wound full-thick closure for perineal wound of abdominoperineal resection for rectal carcinoma: A prospective cohort trial. Int Wound J 2020; 17:1817-1828. [PMID: 32755065 PMCID: PMC7754419 DOI: 10.1111/iwj.13470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022] Open
Abstract
Perineal wound complications after APR have high morbidity in the colorectal surgical department. Although some approaches have been figured out to solve this clinical focus, the outcomes are still not satisfied. Herein, this prospective comparative clinical trial has been designed to evaluate a new surgical procedure of direct perineal wound full-thick closure (DPWC), compared with conventional perineal wound closure (CPWC), with hopes of making wound healing with less complications. In addition, an evaluation of an incision negative wound pressure therapy, as another focus in this field, was also analysed in the DPWC group. A total of 44 participants in our department were recruited from March 2018 to March 2020, divided into two groups randomly, CPWC group and DPWC group. The patients' characteristics, such as age, gender, BMI, smoking, alcohol consumption, comorbidities, CEA level, and high-risk of invasion, were recorded without statistical significance between the CPWC group and DPWC group. After the same standard abdominal phase, these two groups were performed in different perineal phases. And then, operative and postoperative outcomes were analysed with different statistical methods. Data on wound healing time and length of stay in the DPWC group were shorter than those in the CPWC group (P < .05). Furthermore, cases of wound infection within 30 days in the DPWC group were also less than that in the CPWC group (P < .05). However, no difference was found between the incisional negative pressure wound therapy assisted group (NPA group) and non- incisional negative pressure wound therapy assisted group (non-NPA group). During this study, hypoalbuminemia, as an independent high-risk factor, impacted perineal wound healing. (P = .0271) In conclusion, DPWC is a new surgical approach, which can lead to a better outcome than DPWC, and it can be another surgical procedure for clinicians. In addition, hypoalbuminemia should be interfered for avoiding perineal wound complications.
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Affiliation(s)
- Yong‐Ping Yang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Ling‐Yun Yu
- The Department of Ear Nose and Throat Surgerythe First Hospital of Jilin UniversityChangchunChina
| | - Min Wang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Yu Mu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Jian‐Nan Li
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Feng‐Jia Shang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Xian‐Feng Wu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Tong‐Jun Liu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Jian Shi
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
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33
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LaBove GA, Evans GR, Biggerstaff B, Richland BK, Lee SA, Banyard DA, Khoshab N. Ten-Year experience with vertical rectus abdominis myocutaneous flap for reconstruction of abdominoperineal resection defects. JPRAS Open 2020; 27:90-98. [PMID: 33376767 PMCID: PMC7758273 DOI: 10.1016/j.jpra.2020.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose We evaluate outcomes of our single center using vertical rectus abdominis myocutaneous (VRAM) flaps for reconstruction after abdominoperineal resection (APR). Our goal was to analyze factors that may affect perineal wound healing, a problematic complication with APR reconstructions due to location and high frequency of neoadjuvant chemoradiation. Methods This single-center, retrospective study analyzed all VRAM flap perineal reconstruction patients after APR defect over a 10-year period (from July 2008 to June 2018). Outcome measures focused on factors that may affect perineal wound healing complication rates: cancer stage (I/II vs III/IV), neoadjuvant chemoradiation, surgeon's years in practice (<5 years vs >5 years), and pelvic closed suction drain use. Results Twenty-eight patients met inclusion criteria. The overall major perineal wound complication rate was 14.3% (4 patients). Lack of perioperative closed suction pelvic drain use was associated with a significantly higher rate of major perineal wound complications (28.6% vs 0% and p = 0.031). All four major wound complications occurred in patients who did not have a pelvic drain. The major perineal wound complication rate for patients who underwent neoadjuvant chemoradiation was 22% vs 0% with no neoadjuvant chemoradiation (p = 0.107). Conclusion While our cohort represents a relatively small single-center study, our 14.3% rate of major perineal wound complications is consistent with previous studies in the literature. Our findings show that perioperative pelvic closed suction drain use is associated with a lower rate of perineal wound complications. While neoadjuvant chemoradiation trended toward a higher incidence of perineal wound complications, it did not reach statistical significance.
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Affiliation(s)
- Gabrielle A LaBove
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Gregory Rd Evans
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Brian Biggerstaff
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Brandon K Richland
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Seung Ah Lee
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Derek A Banyard
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
| | - Nima Khoshab
- Department of Plastic Surgery, University of California, 200 S. Manchester Ave, Suite 650, Irvine, CA 92868, USA
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D'Annunzio E, Valverde A, Lupinacci RM. PERINEAL REPAIR AFTER ABDOMINOPERINEAL EXCISION WITH RECTUS ABDOMINIS MYOCUTANEOUS FLAP. ACTA ACUST UNITED AC 2020; 33:e1507. [PMID: 33237159 PMCID: PMC7682142 DOI: 10.1590/0102-672020190001e1507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/17/2020] [Indexed: 11/22/2022]
Abstract
Background: Abdominoperineal excision of the rectum (APR) remains the only potential
curative treatment for very low rectal adenocarcinoma and squamous cell
carcinoma of the anus. Yet, it implies a significant perineal exenteration
and has set the attention on the perineal reconstruction. Aim: To present technique used in one case of APR for anal cancer, with resection
of the vaginal posterior wall with large perineal defect which has called
for the necessity of a flap for reconstruction Method: To cover the large perineal defect and reconstruct the posterior vaginal wall
was perform a standardized and reproducible surgical technique using oblique
rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap
is thick and well vascularized by both superficial branches and perforators
of the superior epigastric artery and the deep inferior epigastric artery
which serves as the vascular pedicle for the ORAM flap. Results: This procedure was applied in a 65-year-old woman with recurrent squamous
cell carcinoma of the anus infiltrating the posterior wall of the vagina.
Was performed an APR with en-bloc resection of the vaginal posterior wall in
order to achieve tumor-free margins. Postoperative course was uneventful and
she was discharged home at postoperative day 9. Final pathological report
confirmed the oncological adequacy of the procedure (R0) and showed a
rypT4N0 lesion. Conclusion: Flap reconstruction is an effective way to cover the perineal wound reducing
both perineal complication rate and wound healing delay. The ORAM is
particularly interesting for female whose tumors require resection and
subsequent reconstruction of the posterior wall of the vagina.
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Affiliation(s)
- Elsa D'Annunzio
- Department of Digestive Surgery, Diaconesses Croix Saint Simon Hospital, Paris, France
| | - Alain Valverde
- Department of Digestive Surgery, Diaconesses Croix Saint Simon Hospital, Paris, France
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35
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Murphy C, Stephens I, OꞌFlanagan G, OꞌByrne L, Reynolds IS, Ajmal N, O'Sullivan JB, OꞌNeill B, Deasy J, Burke JP, McNamara DA. A comparison of oncological outcomes after abdominoperineal excision before and after the implementation of a selective perineal flap closure program. J Surg Oncol 2020; 123:614-621. [PMID: 33238062 DOI: 10.1002/jso.26309] [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: 08/20/2020] [Revised: 10/12/2020] [Accepted: 11/08/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Abdominoperineal excision (APE) is the operation chosen when a patient has low rectal cancer unamenable to sphincter preserving surgery. Perineal flap reconstruction is associated with less wound morbidity but little is known about oncological outcomes. The objective was to compare outcomes in patients undergoing APE before and after the introduction of a program that utilized flap reconstruction of the perineum. METHODS A retrospective review of a prospectively maintained database was performed. Patients who underwent APE followed by primary closure or flap reconstruction between 1998 and 2018 were selected. The cohorts were divided according to the implementation of the flap reconstruction program in July 2009. Clinicopathological data, recurrence and survival were compared between the cohorts. RESULTS One hundred and forty nine patients underwent APE for rectal adenocarcinoma between 1998 and 2018. There were 57 patients in the pre-flap era and 92 in the post-flap era. Forty-six patients underwent flap reconstruction in the latter cohort (50%). More patients in the post-flap era underwent neoadjuvant chemoradiotherapy (85.9% vs. 63.2%; p < .01). Margin positivity rates decreased from 21.1% in the pre-flap era to 10.9% in the post-flap era (p = .10) and there was an associated improvement in incidence and time to local recurrence (p = .03). CONCLUSION The use of perineal flap reconstruction is associated with a longer median time to local recurrence. Perineal flap reconstruction may contribute to reduced margin positivity.
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Affiliation(s)
- Claudine Murphy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ian Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Grace OꞌFlanagan
- Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
| | - Lisa OꞌByrne
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.,Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nadeem Ajmal
- Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
| | - John Barry O'Sullivan
- Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
| | - Brian OꞌNeill
- Department of Radiation Oncology, Beaumont Hospital, Dublin, Ireland
| | - Joseph Deasy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Deborah A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3177. [PMID: 33173689 PMCID: PMC7647507 DOI: 10.1097/gox.0000000000003177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/18/2020] [Indexed: 01/10/2023]
Abstract
Cancer, trauma, infection, or radiation can cause perineal defects. Fasciocutaneous flaps based on perforator vessels (PV) from the internal pudendal artery (IPA) provide an ideal reconstructive option for moderate defects. We hypothesized that, due to gender differences in the pelvic–perineal region, the anatomical distribution of PV differs between genders.
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37
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Copeland-Halperin LR, Stewart T, Chen Y, Funderburk CD, Freed GL. Perineal reconstruction following abdominoperineal resection: Comprehensive review of the literature. J Plast Reconstr Aesthet Surg 2020; 73:1924-1932. [DOI: 10.1016/j.bjps.2020.08.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/24/2020] [Indexed: 12/12/2022]
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38
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Options and outcomes of soft tissue reconstruction in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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39
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Jafari M, Schneider-Bordat L, Hersant B. Biological mesh used to repair perineal hernias following abdominoperineal resection for anorectal cancer. ANN CHIR PLAST ESTH 2020; 65:e15-e21. [PMID: 32517871 DOI: 10.1016/j.anplas.2019.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/20/2019] [Accepted: 12/02/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to determine the outcome for patients who had undergone perineal hernia repair, via a perineal approach, using a biological mesh post-abdominoperineal excision (APE) for anorectal cancer. METHOD All consecutive patients having undergone perineal hernia repair involving an extracellular matrix of porcine small intestinal submucosa at our hospital between 2015 and 2018 were included. Follow-up clinical examinations and computed tomography scans were performed. RESULTS Six patients were treated surgically for symptomatic perineal hernia after a median of 31 months from APE. The median follow-up after hernia repair was 11 months (interquartile range [IQR], 6-35 months). Three patients (50%) developed a recurrent perineal hernia after a median interval of 6 months. CONCLUSION Perineal hernia repair using a biological mesh resulted in a high recurrence rate in patients who had undergone APE for anorectal cancer.
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Affiliation(s)
- M Jafari
- Service de chirurgie oncologique, centre Oscar-Lambret, 3, rue Combemale, 59020 Lille cedex, France.
| | - L Schneider-Bordat
- Service de chirurgie oncologique, centre Oscar-Lambret, 3, rue Combemale, 59020 Lille cedex, France
| | - B Hersant
- Service de chirurgie plastique, reconstructrice, esthétique, et maxillo-faciale, hôpitaux universitaires Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
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40
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Horch RE, Ludolph I, Cai A, Weber K, Grützmann R, Arkudas A. Interdisciplinary Surgical Approaches in Vaginal and Perineal Reconstruction of Advanced Rectal and Anal Female Cancer Patients. Front Oncol 2020; 10:719. [PMID: 32477947 PMCID: PMC7237715 DOI: 10.3389/fonc.2020.00719] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022] Open
Abstract
Relapsing or far advanced rectal and anal cancers remain difficult to treat and require interdisciplinary approaches. Due to modern standard protocols all patients receive irradiation and neoadjuvant chemotherapy-and in case of a relapse a second irradiation-rendering the surgical site prone to surgical site infections and oftentimes long lasting sinus and septic complications after exenteration in the pelvis. Despite an improved overall survival rate in these patients the downside of radical tumor surgery in the pelvis is a major loss of quality of life, especially in women when parts of the vagina need to be resected. Derived from our experince with over 300 patients receiving pelvic and perineal reconstruciton with a transpelvic vertical rectus abdominis myocutaneous (tpVRAM) flap we studied the impact of this surgical technique on the outcomes of female patients with or without vaginal reconstruction following pelvic exenteration. We found out that the tpVRAM flap is reliably perfused and helps to reduce long term wound healing desasters in the irradiated perineal/vaginal/gluteal region.
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Affiliation(s)
- Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Aijia Cai
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University Hospital Erlangen-Friedrich Alexander University of Erlangen-Nuernberg FAU, Erlangen, Germany
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41
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Baird DLH, Pellino G, Rasheed S, Power KT, Kontovounisios C, Tekkis PP, Ramsey KW. A Comparison of the Short-term Outcomes of Three Flap Reconstruction Techniques Used After Beyond Total Mesorectal Excision Surgery for Anorectal Cancer. Dis Colon Rectum 2020; 63:461-468. [PMID: 31977583 DOI: 10.1097/dcr.0000000000001585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery for advanced or recurrent pelvic malignancy can result in perineal defects that cannot be closed by wound edge approximation. Myocutaneous flaps can fill the defect and accelerate healing. No reconstruction has been proven to be superior to the others. OBJECTIVE This study aimed to compare 3 flap procedures after beyond total mesorectal excision surgery. DESIGN This is a retrospective analysis of a prospective database, according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. SETTINGS This study was performed at a tertiary hospital. PATIENTS Consecutive series of patients who required flap reconstruction after beyond total mesorectal excision surgery between 2007 and 2016 were included. MAIN OUTCOME MEASURES Short-term outcomes after oblique rectus abdominis flap vs vertical rectus abdominis flap vs inferior gluteal artery perforator flap reconstruction were evaluated. RESULTS Included are 65 (59%) oblique rectus abdominis flap, 30 (27.3%) vertical rectus abdominis flap, and 15 (13.7%) inferior gluteal artery perforator flap outcomes. Sacrectomy was performed in 12 (18.5%), 10 (33.3%), and 8 (53.3%) patients (p = 0.016). Preoperative radiotherapy was used in 60 (92.3%), 26 (86.7%), and 11 (73.3%) patients (p = 0.11). Flap infection and dehiscence occurred in 7 (10.8%), 1 (3.3%), and 4 (26.7%) patients. There was an increased risk of flap complication with inferior gluteal artery perforator flap vs vertical rectus abdominis flap (p = 0.036). Inferior gluteal artery perforator flap (OR, 6.26; p = 0.02) and obesity (OR, 4.96; p = 0.02) were associated with flap complications. Only complications of the oblique rectus abdominis flap decreased significantly over time (p = 0.03). The length of stay and complete (R0) resection rate were not different between the groups. LIMITATIONS This study was limited because of its retrospective nature and because it was conducted at a single center. CONCLUSIONS The techniques appear comparable. The approaches should be considered complementary, and the choice should be individualized. See Video Abstract at http://links.lww.com/DCR/B141. COMPARACIÓN DE RESULTADOS A CORTO PLAZO DE TRES TÉCNICAS DE RECONSTRUCCIÓN CON COLGAJO UTILIZADAS DESPUÉS DE LA CIRUGÍA DE ESCISIÓN MESORRECTAL TOTAL EXTENDIDA PARA EL CÁNCER ANORRECTAL: La cirugía para malignidad pélvica avanzada o recurrente puede provocar defectos perineales, que no pueden cerrarse por aproximación de los bordes de la herida. Los colgajos miocutáneos pueden llenar el defecto y acelerar la curación. Ninguna reconstrucción ha demostrado ser superior a las demás.Comparar tres procedimientos de colgajo después de una cirugía de escisión mesorrectal total extendida.Análisis retrospectivo de una base de datos prospectiva, de acuerdo con la Declaración de Fortalecimiento de los informes de estudios observacionales en epidemiología.Hospital de tercer nivel.Series consecutivas de pacientes que requirieron reconstrucción con colgajo después de una cirugía de escisión mesorrectal total extendida entre 2007 y 2016.Resultados a corto plazo después del colgajo oblicuo recto abdominal versus colgajo vertical recto abdominal versus reconstrucción del colgajo perforador de la arteria glútea inferior.Se incluyen 65 (59%) colgajo oblicuo recto abdominal oblicuo, 30 (27.3%) colgajo vertical recto abdominal y 15 (13.7%) colgajo perforador de la arteria glútea inferior. Sacrectomía se realizó en 12 (18.5%), 10 (33.3%) y 8 (53.3%) pacientes respectivamente (p = 0.016). La radioterapia preoperatoria se utilizó en 60 (92.3%), 26 (86.7%) y 11 (73.3%) (p = 0,11). La infección del colgajo y la dehiscencia ocurrieron en 7 (10.8%), 1 (3.3%) y 4 (26.7%). Hubo un mayor riesgo de complicación con el colgajo perforador de la arteria glútea inferior en comparación al colgajo vertical del recto abdominal (p = 0.036). El colgajo perforador de la arteria glútea inferior (OR 6.26, p = 0.02) y la obesidad (OR 4.96, p = 0.02) se asociaron con complicaciones del colgajo. Solo las complicaciones del colgajo oblicuo recto abdominal disminuyeron significativamente con el tiempo (p = 0.03). La duración de la estancia hospitalaria y la tasa de resección completa (R0) no fue diferente entre los grupos.Estudio retrospectivo en centro único.Las técnicas parecen comparables. Los enfoques deben considerarse complementarios y la elección individualizada. Consulte Video Resumen en http://links.lww.com/DCR/B141.
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Affiliation(s)
- Daniel L H Baird
- Department of Colorectal Surgery, Royal Marsden Hospital, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Gianluca Pellino
- Department of Colorectal Surgery, Royal Marsden Hospital, London, United Kingdom
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, United Kingdom
| | - Kieran T Power
- Department of Plastic Surgery, Royal Marsden Hospital, London, United Kingdom
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, United Kingdom
| | - Paris P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, United Kingdom
| | - Kelvin W Ramsey
- Department of Plastic Surgery, Royal Marsden Hospital, London, United Kingdom
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A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer. Ann Surg 2020; 271:654-662. [DOI: 10.1097/sla.0000000000003266] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Comparison of Effective Cost and Complications after Abdominoperineal Resection: Primary Closure versus Flap Reconstruction. Plast Reconstr Surg 2020; 144:866e-875e. [PMID: 31688766 DOI: 10.1097/prs.0000000000006158] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Flap reconstruction is recommended for select patients undergoing abdominoperineal resection to mitigate complications. However, the clinical effectiveness and financial implications of flap reconstruction remain unknown. The authors aim to compare the costs and complications for patients undergoing abdominoperineal resection with and without flap reconstruction. METHODS The Truven MarketScan Databases (2009 to 2016) were used to perform retrospective population-based analysis of colorectal carcinoma patients who underwent abdominoperineal resection with and without flap reconstruction. Univariate and multivariable logistic regressions were used to study effective cost (cumulative cost/number of healthy days) and complications. RESULTS Of 2557 total abdominoperineal resection patients, 194 patients underwent flap reconstruction. Patients undergoing flap reconstruction had a higher Elixhauser Comorbidity Index (p = 0.004) and were more likely to have local invasion (p < 0.001). At 6 months postoperatively, there were no differences in complications between the two groups (p = 0.116). Flap reconstruction was protective against intraabdominal infections (OR, 0.4; 95 percent CI, 0.2 to 0.9; p = 0.033) but conferred an increased risk of wound complications (OR, 1.5; 95 percent CI, 1.0 to 2.3; p = 0.039). Total median cost of care was similar (abdominoperineal resection alone, $40,050; abdominoperineal resection with flap, $41,380; p = 0.456). Effective cost was greater for abdominoperineal resection alone ($259/healthy day) than abdominoperineal resection with flap ($186/healthy day) but was not statistically significant (p = 0.17). CONCLUSIONS Patients with flap reconstruction displayed a higher comorbidity score and more extensive disease, but these unfavorable factors did not result in a higher complication rate, total cost, or effective cost. Therefore, flap reconstruction for complex perineal defects confers a benefit in select patients and is a judicious use of health care resources. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Reconstruction of Intrapelvic Defects Using the Free Anterolateral Thigh Flap: Expanding the Traditional Algorithm. Ann Plast Surg 2019; 84:554-558. [PMID: 31688115 DOI: 10.1097/sap.0000000000002048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reconstruction of intrapelvic soft tissue defects traditionally relies on regional pedicled myocutaneous flaps. However, there remain situations in which local options are unavailable. We review our experience treating intrapelvic defects with the anterolateral thigh (ALT) microvascular free flap. METHODS A retrospective, institutional review was conducted from 2014 to 2018 of patients undergoing microvascular ALT flap reconstruction of intrapelvic defects. Four patients were identified in this cohort out of 92 total pelvic reconstruction cases. RESULTS All patients underwent abdominoperineal resection (APR) for rectal cancer treatment. In the two male patients, pelvic abscesses and bladder leak necessitated soft tissue reconstruction after radiation and APR. In both, regional tissue options were unavailable, and a buried ALT free flap was used for soft tissue reconstruction. Both female patients developed rectovaginal fistulas secondary to their tumor burden, necessitating posterior vaginal wall resections. Prior surgical scars and ostomies made abdominal wall tissue unavailable; thus, free ALTs were used to eliminate intrapelvic dead space and reconstruct the posterior vaginal wall. In all cases, recipient vessels were the deep inferior epigastric artery and vein. Flap survival was 100%. CONCLUSIONS Pelvic reconstruction has traditionally been addressed with local/regional pedicled flaps. In cases where these are unavailable, the free ALT flap is a versatile option when buried for intrapelvic reconstruction or posterior vaginal wall lining. We also propose updating Cordeiro et al.'s classic vaginal defect reconstruction algorithm to include the free ALT flap for type IB cases in which the rectus abdominis is unavailable.
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Bertrand K, Lefevre JH, Creavin B, Luong M, Debove C, Voron T, Chafai N, Tiret E, Parc Y. The management of perineal hernia following abdomino-perineal excision for cancer. Hernia 2019; 24:279-286. [PMID: 30887380 DOI: 10.1007/s10029-019-01927-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 03/11/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Perineal hernia (PH) is a tardive complication following abdomino-perineal resection (APR). Many repair methods are described and evidences are lacking. The aim of this study was to report PH management, analyze surgery outcomes and review the available literature. METHODS We retrospectively included all consecutive PH repair after APR performed between 2001 and 2017. We recorded data on APR surgery, PH symptoms and repair, and follow-up (recurrence and morbidity). Literature review included published articles on PubMed between 1960 and 2017. RESULTS 24 PH repairs were included. The approach was perineal N = 16, abdominal N = 5 and combined N = 3. A biological mesh was used for 17, a synthetic for 5 and a flap for 2 patients. The median follow-up was 25 months. Overall morbidity was 37.5% (N = 9): 37.5% for the perineal, 20% for the abdominal, and 66.7% for the combined approach. Complications occurred in 35.3% of biological and 20% of synthetic mesh repairs. Recurrence rate was 41.7%, similar for biological (n = 8, 47.1%) and synthetic meshs (n = 2; 40%). No recurrence occurred in the flap group. Depending of the approach, we found 50% for perineal (n = 8) and 40% of the abdominal cohort (N = 2). Among twelve studies, recurrence rates ranged from 0 to 66.7%. Abdominal or laparoscopic approach with synthetic mesh was associated with less recurrences (0 and 12.5% respectively) and complications (37.5% and 9.5%). CONCLUSIONS Recurrences following PH repair are high irrespective of the repair technique. More studies are necessary to identify PH risk factors and decide the appropriate perineal reconstruction.
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Affiliation(s)
- K Bertrand
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
| | - J H Lefevre
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France.
| | - B Creavin
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - M Luong
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
| | - C Debove
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
| | - T Voron
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
| | - N Chafai
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
| | - E Tiret
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
| | - Y Parc
- Departments of Digestive and General Surgery, Hospital Saint-Antoine AP-HP, Sorbonne Université, Paris, France
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The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects. Int J Colorectal Dis 2019; 34:501-511. [PMID: 30610436 DOI: 10.1007/s00384-018-03222-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 02/04/2023]
Abstract
AIM Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.
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Yang XY, Wei MT, Yang XT, He YZ, Hao Y, Zhang XB, Deng XB, Wang ZQ, Zhou ZQ. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis 2019; 21:138-155. [PMID: 30428157 DOI: 10.1111/codi.14471] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
AIM Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease. METHODS We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure. RESULTS Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.
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Affiliation(s)
- X Y Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - M T Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X T Yang
- Wound Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Y Z He
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Y Hao
- West China School of Public Health, Sichuan University, Chengdu, China
| | - X B Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - X B Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Z Q Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Kin C. So Now My Patient Has Squamous Cell Cancer: Diagnosis, Staging, and Treatment of Squamous Cell Carcinoma of the Anal Canal and Anal Margin. Clin Colon Rectal Surg 2018; 31:353-360. [PMID: 30397394 DOI: 10.1055/s-0038-1668105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Squamous cell carcinomas of the anal canal and the anal margin are rare malignancies that are increasing in incidence. Patients with these tumors often experience delayed treatment due to delay in diagnosis or misdiagnosis of the condition. Distinguishing between anal canal and anal margin tumors has implications for staging and treatment. Chemoradiation therapy is the mainstay of treatment for anal canal squamous cell, with abdominoperineal resection reserved for salvage treatment in cases of persistent or recurrent disease. Early anal margin squamous cell carcinoma can be treated with wide local excision, but more advanced tumors require a combination of chemoradiation therapy and surgical excision.
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Affiliation(s)
- Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Calotta NA, Coon D, Bos TJ, Ostrander BT, Scott AV, Grant MC, Efron JE, Sacks JM. Early ambulation after colorectal oncologic resection with perineal reconstruction is safe and effective. Am J Surg 2018; 218:125-130. [PMID: 30471809 DOI: 10.1016/j.amjsurg.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/18/2018] [Accepted: 10/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative bedrest is common following perineal reconstruction despite little supporting data. We sought to determine the safety of early ambulation following colorectal oncologic resection and flap-based perineal reconstruction. METHODS A retrospective cohort study was conducted with two cohorts: standard bedrest (BC) and early ambulation (EAC). Ambulation capacity was objectively assessed. Regression analysis was performed to determine the effects of ambulation timing on 60-day reoperations or readmissions and other surgical outcomes. RESULTS There were 57 participants. Those in the EAC were significantly more ambulatory on post-operative days one through three (p < 0.0001). There was no significant difference in 60-day reoperations (25% BC versus 9% EAC, p = 0.14) or readmissions (33% BC versus 15% EAC, p = 0.12). Early ambulation significantly reduced minor complication rates (38% BC versus 9% EAC, p = 0.02). CONCLUSIONS Early ambulation following perineal reconstruction is safe and may potentially decrease wound complications. SUMMARY AND KEYWORDS Institution of early ambulation protocols is rapidly becoming the standard of care for many oncological surgery patients. In cases requiring perineal reconstruction with vascularized flaps, however, there is no data to uproot the historical practice of mandatory bedrest. Our study demonstrates that the benefits of early ambulation are attainable in these patients without compromising reconstructive outcomes.
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Affiliation(s)
- Nicholas A Calotta
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Devin Coon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tobias J Bos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Benjamin T Ostrander
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew V Scott
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018). Dis Colon Rectum 2018; 61:755-774. [PMID: 29878949 DOI: 10.1097/dcr.0000000000001114] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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