Risk factors for wound complications in patients undergoing primary closure of the perineal defect after total proctectomy

Perineal wound complications after total neoadjuvant therapy or chemoradiotherapy followed by abdominoperineal excision in patients with high-risk locally advanced rectal cancer in the RAPIDO trial

BACKGROUND

Perineal wound complications (PWCs) occur in 15-30% of patients after abdominoperineal excision (APE) and are associated with adverse events, such as delayed wound healing, prolonged hospitalization, a delay in initiating postoperative chemotherapy, and decreased quality of life. Preoperative radiotherapy and chemotherapy are risk factors for wound complications. It is unknown whether total neoadjuvant treatment (TNT) affects the risk of PWCs compared with chemoradiotherapy (CRT).

METHODS

This study compared patients from the experimental (EXP; short-course radiotherapy, chemotherapy, and surgery as TNT) and standard-of-care (STD; CRT, surgery, and postoperative chemotherapy depending on hospital policy) treatment arms of the RAPIDO trial who underwent APE within 6 months after preoperative treatment. The primary outcome was the incidence of PWCs (infection, abscess, dehiscence, wound discharge, presacral abscess affecting the perineum) of any grade ≤ 30 days after APE. Secondary outcomes were the incidence of PWCs >30 days after APE, length of hospital stay, characteristics associated with PWCs, and oncological outcomes in patients with versus without PWC.

RESULTS

Of the 901 patients who started treatment (460 in EXP arm, 441 in STD arm), 153 (33%) and 160 (36%) underwent APE after TNT and CRT, respectively. After TNT and CRT, the incidence of PWCs ≤30 days after APE, readmission, and reoperation was 54 of 153 (35%) versus 53 of 160 (33%) (P = 0.69), 9% versus 12% (P = 0.54), and 7% versus 8% (P = 0.75), respectively. The median length of hospital stay was 2-3 days longer for patients with PWC. Univariable analysis revealed that pretreatment albumin <35 g/l, hypertension, and haemoglobin ≤ 8.0 mmol/l were associated with PWC. Oncological outcomes were similar between patients with and without PWCs.

CONCLUSION

In the RAPIDO trial, TNT and CRT resulted in a similar incidence of PWCs among patients with high-risk locally advanced rectal cancer who underwent APE.

How to Approach the Difficult Perineum in Crohn's Disease

Crohn's disease (CD) is a chronic, inflammatory bowel disease with a wide range of presentations, including perianal disease. Presentation is variable, ranging from skin tags to complex fistulas, strictures, and nonhealing wounds. Symptoms of perianal CD can be devastating and may impact quality of life. Optimal management requires coordinated medical and surgical therapy. When possible, conservative treatment of perianal disease should be attempted. However, surgical treatment is often required, and some patients may ultimately require total proctocolectomy with permanent diversion due to the severity of disease. Even with close attention and treatment, disease can be recurrent, and complications of treatment are sometimes worse than the initial presentation. Novel treatments, including use of mesenchymal stem cells and autologous fat grafting, hold some promise, but are not yet widely available. Thorough knowledge of treatment options, careful patient selection, coordination between medical and surgical providers, and setting realistic expectations are important in the successful treatment of difficult perineal CD.

Gracilis Flap Reconstruction After Proctocolectomy for Malignancy and Inflammatory Bowel Disease

BACKGROUND

Gracilis flap reconstruction (GFR) following abdominoperineal resection (APR) or proctocolectomy (PC) can reduce pelvic wound complications but has not been adequately assessed in the setting of immunosuppression, fistulous disease, and neoadjuvant chemoradiation.

METHODS

Patients undergoing APR/PC with GFR were retrospectively analyzed with regard to perioperative characteristics, and morbidity was assessed.

RESULTS

Patients underwent GFR for rectal cancer (n = 28), anal cancer (n = 3), inflammatory bowel disease (n = 13), or benign fistulizing disease (n = 1). 22.2% were chronically immunosuppressed, and 66.7% underwent preoperative chemoradiation. Twenty (44.4%) patients had minor wound complications, all treated nonoperatively. Nine patients had major complications with 4 patients requiring reoperation. The 4 threatened flaps were unilateral, and all were salvaged. Donor site morbidity was minimal. Patients with major complications were older (56 vs. 71 years, P = .030), and less likely to have pelvic drains (P = .018).

CONCLUSION

In high-risk perineal wounds, GFR offers durable reconstruction with acceptably low morbidity.

Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study

PURPOSE

Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30 days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model.

RESULTS

A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3).

CONCLUSION

Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.

Perineal wound complication risk factors and effects on survival after abdominoperineal resection of rectal cancer: a single-centre retrospective study

PURPOSE

This study determined the risk factors associated with perineal wound complications (PWCs) and investigated their effect on overall survival in patients with rectal cancer who underwent abdominoperineal resection (APR).

METHODS

The clinicopathologic and follow-up data of patients who underwent APR for primary rectal cancer between 1998 and 2018 were reviewed. PWCs were defined as any perineal wound that required surgical intervention, antibiotics, or delayed healing for more than 2 weeks. The primary objective was identifying the risk factors of PWC after APR. The effect of PWC on survival was also investigated as a secondary objective.

RESULTS

Two hundred and twenty patients were included in the final analyses and 49 had PWCs. An operative time of > 285 min (odds ratio: 2.440, 95% confidence interval (CI): 1.257-4.889) was found to be independently associated with PWCs. When the follow-up time was > 60 months, patients with PWCs had a significantly lower overall survival rate than patients without PWC (n = 156; mean over survival: 187 and 164 months in patients without and with PWCs, respectively; P = 0.045). Poor differentiation (hazard ratio (HR): 1.893, 95% CI: 1.127-3.179), lymph node metastasis (HR: 2.063, 95% CI: 1.228-3.467), and distant metastasis (HR: 3.046, 95% CI: 1.551-5.983) were associated with poor prognosis.

CONCLUSION

Prolonged operative time increases the risk of PWCs, and patients with PWCs have a lower long-term survival rate than patients without PWCs. Therefore, surgeons should aim to reduce the operative time to minimise the risk of PWC in patients undergoing APR for rectal cancer.

Lotus petal flap and vertical rectus abdominis myocutaneous flap in vulvoperineal reconstruction: a systematic review of differences in complications

BACKGROUND

Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps. Methods: A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines. Results: A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%). Conclusions: Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates. Abbreviations: APE: abdominoperineal excision; ELAPE: extra levator abdominoperineal excision; LP flap: lotus petal flap; NIH: National Institute of Health; NR: not reported; RCT: randomized controlled trial; VRAM flap: vertical rectus abdominis myocutaneous flap.

Analysis of influencing factors of no/low response to preoperative concurrent chemoradiotherapy in locally advanced rectal cancer

The aim of this study is to investigate the influencing factors associated with no/low response to preoperative concurrent chemoradiotherapy (CCRT) for locally advanced rectal cancer (LARC) patients. A total of 79 patients were included in this prospective study. Fifteen factors that might affect the resistance to CCRT were included in this logistic regression analysis, these factors include the general clinical data of patients, the expression status of tumor stem cell marker CD44v6 and the volumetric imaging parameters of primary tumor lesions. We found that the no/low response status to preoperative CCRT was positively correlated with the real tumor volume (RTV), the total surface area of tumor (TSA), and CD44v6 expression, whereas negatively correlated with the tumor compactness (TC). According to the results of logistic regression analysis, two formulas that could predict whether or not no/low response to preoperative CCRT were established. The Area Under Curve (AUC) of the two formulas and those significant measurement data (RTV, TC, TSA) were 0.900, 0.858, 0.771, 0.754, 0.859, the sensitivity were 95.8%, 79.17%, 62.50%, 95.83%, 62.5%, the specificity were 70.9%, 74.55%, 83.64%,47.27%, 96.36%, the positive predictive values were 58.96%, 57.58%, 62.51%,44.23%, 88.23%, the negative predictive values were 97.48%, 89.13%, 83.64%, 96.29%, and 85.48%, respectively.

Pelvic peritoneum closure reduces postoperative complications of laparoscopic abdominoperineal resection: 6-year experience in single center

BACKGROUND

To investigate feasibility of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LAPR-PPC) for lower rectal cancer.

METHODS

LAPR-PPC has been used for lower rectal cancer in our institution since 2014. In this study, we retrospectively analyzed the data from 86 patients who underwent LAPR-PPC and compared with the data from 96 patients who underwent laparoscopic APR without PPC (LAPR) from January 2013 to December 2018.

RESULTS

The rate of perineal surgical site infection (SSI) (18.75% (18/96) vs. 5.81% (5/86), p < 0.01), delayed (> 4 weeks) perineal healing (12.50% (12/96) vs. 3.49% (3/86), p = 0.027), ileus (7.29% (7/96) vs 1.16% (1/86), p = 0.044), and postoperative perineal hernia (PPH, 5.21% (5/96) vs. 0% (0/86), p = 0.032) were significantly lower in LAPR-PPC group than LAPR group. The patients in LAPR-PPC group had shorter hospitalization time (21.32 ± 11.95 days vs. 13.93 ± 11.51 days, p < 0.01).

CONCLUSIONS

PPC procedure enabled the reduction in perineal wound complications, ileus, PPH, and consequently shortened hospitalization time. LAPR-PPC is beneficial for the patients with lower rectal cancer.

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

Current issues of preoperative radio(chemo)therapy and its future evolution in locally advanced rectal cancer

Neoadjuvant therapies are effective for local control and tumor downstaging. Up to date, preoperative long-course chemoradiotherapy and short-course radiotherapy are the two primary guideline-recommended neoadjuvant therapies for locally advanced rectal cancer patients. However, clinicians throughout the world are trying their best to further optimize the regimens and concepts of neoadjuvants. Hence, there is an urgent need to summarize evidence regarding indications of neaoadjuvant therapies and relative merits of current standard regimens. In addition, we also reviewed the optimized regimens mainly based on short-course radiotherapy with delayed surgery, consolidation chemotherapy, induction chemotherapy, chemotherapy alone without radiation and concepts in terms of organ preservation and personalized treatments to further explore the future evolution of neoadjuvant therapies in rectal cancer.