Primary closure of complicated perineal wounds with myocutaneous and fasciocutaneous flaps after proctectomy for Crohn's disease

Perineal wound complications after proctectomy for Crohn's disease: the impact of the omental pedicle flap and predictors of return to the operating room

BACKGROUND

The role of omental pedicle flaps (OPFs) in reducing the risk of perineal wound complications and postoperative pelvic abscesses in patients with Crohn's disease remains unclear. This study aimed to determine whether OPFs had any effect on the incidence of perineal wound complications requiring a return to the operating room (OR) or the requirement for radiologic-guided drainage of pelvic abscesses in patients with Crohn's disease who underwent proctectomy.

METHODS

This was a retrospective, single-center study. The study included patients who underwent proctectomy for Crohn's disease with primary perineal closure, with or without an OPF. The primary outcome measures were return to the OR for perineal wound complications or the requirement for radiologically guided drainage of pelvic abscesses.

RESULTS

A total of 219 patients (71 with flap and 148 without flap) underwent proctectomy during the study period. No differences were observed in the rate of unplanned return to the OR (11.27% in the OPF group vs 9.46% in the non-OPF group; P =.81) or the number of patients requiring radiologically guided drainage of pelvic abscesses (11.27% in the OPF group vs 6.76% in the non-OPF group, respectively; P =.30) between the cohorts. Patients in the flap cohort were more likely to have a history of tobacco use (P =.02), fistulizing perianal disease (P =.01), undergo extrasphincteric dissection (P =.03), and use incisional wound vacuum assisted closure (VAC) at the time of surgery (P =.02).

CONCLUSION

Careful patient selection for the OPF might play a role in reducing wound complications to a level similar to that observed in patients with lower-risk perineal wounds.

Long-Term Complications of Proctectomy for Refractory Perianal Crohn's Disease: A Narrative Review

Despite a combination of medical and surgical treatments, many patients with perianal Crohn's disease (CD) continue to experience refractory disease, requiring proctectomy or proctocolectomy, with the creation of a permanent stoma. Although proctectomy is seen as an ultimate treatment aimed at effectively relieving debilitating symptoms and enhancing quality of life, many patients may still face long-term and chronic complications. This narrative review aims to provide an overview of the main complications that patients undergoing proctectomy for CD may experience throughout their lives. Relevant publications addressing complications of proctectomy for refractory perianal CD were searched in the Medline/PubMed, Embase, Cochrane, and LILACS databases. The main long-term complications that patients encounter are related to impaired perineal wound healing, stoma-related issues, sexual and urinary dysfunction, small bowel obstructions, and CD recurrence. These complications negatively affect the quality of life and frequently necessitate further treatment. Patients should receive preoperative counselling regarding the implications of these particular issues, and regular follow-up must be guaranteed to identify any problems early, allowing for prompt treatment.

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.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Treatment of perianal Crohn's disease

Perianal Crohn's is a common manifestation of Crohn's disease. Primary manifestations of perianal disease mirror common anorectal conditions, however treatment is less successful than in those patients without Crohn's related perianal disease. A multimodal approach to therapy including medical and surgical modalities is often necessary. The goal of treatment is to manage symptoms while maintaining continence.

Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease

AIM

Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons.

METHOD

Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement.

RESULTS

Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life.

CONCLUSION

This consensus provides principles and guidance for best practice in managing patients with fpCD.

Perianal Crohn's disease: challenges and solutions

Perianal Crohn’s disease affects a significant number of patients with Crohn’s disease and is associated with poor quality of life. The nature of the disease, compounded by presentation of various disease severities, has made the treatment of perianal Crohn’s disease difficult. The field continues to evolve with the use of both historical and contemporary solutions to address the challenges associated with it. The goal of this article is to review current literature regarding medical and surgical treatment, as well as the future directions of therapy.

IPAA-related sepsis significantly increases morbidity of ileoanal pouch excision

BACKGROUND

Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity.

OBJECTIVE

The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision.

DESIGN

This was a retrospective medical chart review.

SETTINGS

The study was conducted in a single clinical institution.

PATIENTS

Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken.

MAIN OUTCOME MEASURES

Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured.

RESULTS

A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn's disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4-30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363-2182 days), requiring a median of 1.5 procedures.

LIMITATIONS

This was a single-center retrospective review with a small sample size.

CONCLUSIONS

Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.

A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration

PURPOSE

We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps.

METHODS

Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps.

RESULTS

In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %.

CONCLUSIONS

The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.

Factors affecting the healing of the perineum following surgery

INTRODUCTION

The aim of this study was to establish patient and procedural factors associated with the development of an unhealed perineum in patients undergoing a proctectomy or excision of an ileoanal pouch.

METHODS

A review of 194 case notes for procedures performed between 1997 and 2009 was carried out. All patients had at least 12 months' follow-up. Univariate and multivariate analyses were performed in 16 parameters. For those patients who developed an unhealed perineum, Cox regression analysis was performed to establish healing over a 12-month period.

RESULTS

Two hundred patients were included in the study, of which six had unknown wound status and were subsequently excluded. This left 194 study patients. Of these, 86 (44%) achieved primary wound healing with a fully healed perineum and 108 (56%) experienced primary wound failure. With reference to the latter, 63 (58%) healed by 12 months. Comparing patients with an initially intact perineum with those with initial wound failure showed pre-existing sepsis was highly relevant (odds ratio: 4.32, 95% confidence interval [CI]: 2.16-8.62, p<0.001). In patients who had an unhealed perineum initially, perineal sepsis and surgical treatment were both significantly associated with time to healing (hazard ratio [HR]: 0.54, 95% CI: 0.31-0.93, p=0.03; and HR: 0.42, 95% CI: 0.21-0.84, p=0.01).

CONCLUSIONS

The presence of pre-existing perineal sepsis is associated with an unhealed perineum following proctectomy in inflammatory bowel disease (IBD) and non-IBD surgery. Further studies are indicated to establish perineal sepsis as a causative factor.

Prevention and management of nonhealing perineal wounds

Complex perineal wounds are at risk for nonhealing. High-risk procedures include proctectomy for Crohn disease, anal cancer and radiated distal rectal cancers. A basic understanding of both patient and procedural risk factors is helpful in planning and executing operative procedures for these conditions and to minimize associated wound complications. Diabetes, obesity, and malnutrition may contribute to wound breakdown and failure to heal. Delaying operative intervention, adding nutritional supplementation, and employing intestinal diversion as well as myocutaneous flaps may help optimize conditions for wound healing.

Reconstruction of the pelvis and perineum with a free latissimus dorsi myocutaneous flap: a case report

Reconstruction of the perineum and pelvic cavity in continuity is an uncommon and difficult challenge. This case describes a 66-year-old man who presented following recurrence of a Dukes' B rectosigmoid adenocarcinoma that had been treated nine years previously by anterior resection, 5-fluorouracil and radiotherapy. His recurrent disease was treated with radical pelvic exenteration with formation of an end colostomy and urinary ileal conduit. A post-operative pelvic collection necessitated incisional drainage via the perineum. This resulted in a perineal defect in continuity with the pelvic cavity, neither of which healed in spite of alternate day packing with antiseptic dressings. The perineum and cavity were reconstructed successfully with a microvascular transfer of the latissimus dorsi using the primary gracilis pedicle as recipient donor vessels.

[Reconstruction of large tissue loss of the anus and perineum with bilateral inferior gluteal and right gracilis myocutaneous flaps]

The authors present a case of locally advanced anal squamous cell carcinoma which, due to infiltration of deep structures, caused anal incontinence, serious pain, exulceration, and bleeding. Neoadjuvant radiotherapy made the tumour operable and abdominoperineal extirpation was performed. The large tissue loss of the anal and perineal region was covered by bilateral gluteus maximus myocutaneous flaps, and the loss of the pelvic musculature and the remaining pelvic skin loss were replaced by a right gracilis myocutaneous flap. The patient was discharged on the 36th postoperative day. There was no flap necrosis noted and an incomplete lesion of the proximal urethra healed after direct suturing. The patient was allowed to lye on the flap in the second postoperative month and sitting on the third month. Unfortunately, an inoperable infiltrative lymph node metastasis occurred in the right inguinal region after six months, and the patient died 10 months after the surgery. We believe that in cases of large, ulcerating anal tumours, when direct closure would be impossible due to massive tissue loss after resection, quality of life can be significantly improved by resection and closure with myocutaneous flaps.

Proctocolectomy and brooke ileostomy for chronic ulcerative colitis

Proctocolectomy and permanent ileostomy is an option for selected patients with ulcerative colitis. Current indications include the elderly, patients with poor anal continence, and those with malignant lesions of the low rectum. Advantages of this procedure are that it has fewer complications than an ileal pouch-anal anastomosis, it is a one-stage operation removing all the diseased mucosa, and it is a relatively straightforward operation. The operative technique is discussed.

Recent Experience with Abdominal Perineal Resection with Vertical Rectus Abdominis Myocutaneous Flap Reconstruction after Preoperative Pelvic Radiation

Abdominoperineal resection (APR) after pelvic radiation can be complicated by an increased rate of difficult to treat perineal wound complications. In an effort to improve postoperative morbidity after APR, myocutaneous flap reconstructions have been used. We review our recent experience with APR with vertical rectus abdominis myocutaneous flap reconstruction (VRAM) after preoperative pelvic radiation. A retrospective review of patients who underwent APR with VRAM reconstruction after pelvic radiation from December 2004 to July 2008 was conducted. Outcome measures included demographics, comorbidities, length of stay, wound complications, and morbidity and mortality. Fifteen patients with a mean age of 61 ± 9 years underwent APR with VRAM reconstruction. Five patients also required posterior vaginectomy with the APR. Indications for APR were rectal cancer (n = 14, 93%) and anal canal cancer (n = 1, 7%). There were no intraoperative complications. Mean estimated blood loss was 635 ± 446 mL and mean intraoperative blood transfusion requirements were 1 ± 2 units. Mean length of hospital stay was 11 ± 4 days. Six (40%) patients had minor perineal wound complications. One (7%) patient had a perineal wound infection requiring reoperation with washout and reapproximation. There was no 30-day or in-hospital mortality. All VRAM flaps remained viable through follow-up. APR with VRAM flap reconstruction after preoperative pelvic radiation can be performed safely with limited wound complications and no mortality.

The oblique rectus abdominal myocutaneous flap for complex pelvic wound reconstruction

PURPOSE

The oblique rectus abdominal myocutaneous flap is a seldom used flap design based on perforating vessels exiting the rectus near the umbilicus. Compared to other flaps, the oblique rectus abdominal myocutaneous flap provides increased soft tissue to fill pelvic dead space, with the further advantage of intact skin to close perineal defects. Here we detail the oblique rectus abdominal myocutaneous flap in achieving closure of complex perineal wounds.

METHODS

A review of indications and outcomes in 16 patients undergoing complex pelvic operations requiring reconstruction with this flap was undertaken.

RESULTS

All patients had been previously treated with pelvic irradiation for cancer. Indications for flap reconstruction included abdominal perineal resection for anal/rectal cancer, pelvic sarcoma/sacral resection/exenteration, small bowel/colonic fistula resection, and total proctocolectomy with vaginal reconstruction. Median follow-up was 17 (range, 1-57) months. Complications included epidermal necrosis at the flap tip (n = 2), delayed perineal wound breakdown (n = 1), one abdominal wound infection, one small abdominal dehiscence, and four pelvic abscesses all managed nonoperatively. A single recurrent fistula required operative resection three months postoperatively. There were no cases of complete flap necrosis, vascular failure or persistently draining perineal sinus, and no mortalities related to the flap reconstruction.

CONCLUSIONS

The treatment of complex pelvic wounds, especially following pelvic radiation, is facilitated by the oblique rectus abdominal myocutaneous flap. This technique provides ample tissue for large pelvic wounds, including skin for perineal defects. Comparing our results to existing literature, the oblique rectus abdominal myocutaneous flap displays a favorable morbidity profile, providing a safe means of delivering well-vascularized tissue to the pelvic cavity and perineal floor.

Myocutaneous flaps and proctocolectomy in severe perianal Crohn's disease--a single stage procedure

BACKGROUND

Complex perianal wounds can be extremely difficult to treat and primary closure of these defects can be a challenge even for experienced surgeons. So far, myocutaneous flaps for wound closure after removal of malignant tumors are a well-accepted option, but there are only a few reports focusing on the primary closure of the perineal wound after proctocolectomy for Crohn's disease. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal two-team approach.

MATERIALS AND METHODS

We performed proctocolectomy with permanent ileostomy in five patients with longstanding extensive Crohn's disease. All five patients had fistulizing perineal Crohn's disease combined with Crohn's colitis. Each patient received at least one flap for primary wound closure, either a rectus abdominis myocutaneous flap or a gracilis flap.

RESULTS

Indication for surgical intervention included anal or bowel stenosis, septic condition, fecal incontinence, or a combination of these features. One patient had a simultaneous adenocarcinoma of the sigmoid colon. Five patients underwent a total of seven flaps. Three months after surgery, complete healing was achieved in all patients; one patient suffered recurrence in the region of his right thigh. Mean follow up was 19.6 months (range-12-43 months).

CONCLUSIONS

Myocutaneous flaps are a promising therapeutic option in patients with chronic perianal disease. With the transposition of well-vascularized tissue into the perineal defect, complete healing and control of sepsis can be achieved in the majority of patients.

Operative management of Crohn's disease of the colon including anorectal disease

Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.

Guideline proposal to reconstructive surgery for complex perineal sinus or rectal fistula

AIM

To evaluate a guideline approach of reconstructive surgery for complex perineal sinus or rectal fistula.

METHODS

pre-, per-, and postoperative data of 28 patients undergoing transposition of rectus abdominis muscle (TRAM), gracilis muscle (GM), gluteal thigh flap (GTF), or omentoplasty (OP) for complex perineal sinus or rectal fistula were analyzed. A fistula higher than 10 cm and a sinus with a length of >10 cm were treated with TRAM or OP. If <8 cm, the first choice was GM or GTF. The operative team made choice between 8 and 10 cm. Vacuum assisted closure (VAC) therapy was used as adjunct therapy before and after muscle transposition in huge sinus. Success was defined as no residual or recurrent sinus or fistula within 6 months, postoperatively. Long-term complaints of perineum and muscle donor site were assessed.

RESULTS

Twenty-five out of 28 patients (90%) were treated according to the guideline. VAC therapy was done in six. Three patients died during mean follow up of 40 months (6-90). Initial success rate was 61% (17/28). After secondary surgery in seven, four (57%) were successful. Overall success rate, including VAC therapy, was 79% (22/28). Success was highest with GM and GTF and in small sinus or fistula.

CONCLUSION

A guideline approach to complex perineal sinus or fistula based on length or height of the sinus or rectal fistula, respectively, is successful in about 80% of cases. Large defects may best be downsized by VAC therapy, followed by muscle flap. Long-term complaints are acceptable.

Causes and outcomes of pouch excision after restorative proctocolectomy

BACKGROUND

Pouch failure occurs in up to 10 per cent of patients after ileal pouch-anal anastomosis (IPAA). The aims of this study were to determine the reasons for pouch excision and to evaluate the outcome of the perineal wound after pouch excision.

METHODS

Between 1984 and 2002, 91 patients with severe ileal pouch dysfunction were treated. This was a retrospective analysis of data collected prospectively from 24 patients who underwent pouch excision.

RESULTS

Patients were grouped according to the final histological diagnosis. Fourteen patients with Crohn's disease developed extensive fistulous disease and/or recurrent abscesses, of whom six had a persistent perineal sinus after pouch excision. Five patients had familial adenomatous polyposis, in three of whom desmoid tumours were the cause of failure. Three patients had chronic ulcerative colitis and developed recurrent pelvic sepsis. Finally, two patients with multiple colorectal adenocarcinoma developed recurrent cancer (one) or sepsis (one).

CONCLUSION

Sepsis was the principal reason for pouch excision and was usually associated with recrudescent Crohn's disease in the pouch. Perineal wound healing was problematic after pouch excision for Crohn's disease.

Myocutaneous flaps promote perineal healing in inflammatory bowel disease

Rectus abdominis flap seems best

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection

BACKGROUND

Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection.

METHODS

Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy.

RESULTS

Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months).

CONCLUSION

The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

[Plastic reconstructive therapy for postoncologic defect wounds in the pelvis]

Surgical or multimodal therapy of tumors of the pelvis often results in complex defects leading to functional and structural deficits, with the inability to sit or even lie without pain. Multimodal therapy may cause induration of soft tissues and muscles, obstruction of the small bowel, fistulas, and infected cavities. Early soft tissue reconstruction, preferably with myocutaneous flaps, reduces postoperative problems in these patients by early coverage of defects, closure of cavities, and prevention of wound healing complications and therefore allows earlier rehabilitation.

Does the Use of a Flap during Abdominoperineal Resection Decrease Pelvic Wound Morbidity?

We hypothesized that the use of muscle flaps, known as tissue transfer (TT), at the time of abdominoperineal resection (APR) reduces perineal wound complications. A restrospective review of patients undergoing an APR at the University of Washington (1984–2003) was conducted. Perineal wound complications and eventual wound healing were compared in patients with and without TT. Ninety-two patients (mean age, 56.6 years) underwent APR; 23.9 per cent (n = 22) had concurrent TT. Patients undergoing TT were more likely to have cancer (91% vs. 77%, P = 0.05) and radiation therapy (86% vs. 52%, P < 0.01). Operative times were nearly 2 hours longer in patients having TT (7.4 hours ± 2.5 hours vs. 5.6 hours ± 1.8 hours, P = 0.03), but lengths of stay were similar (13 ± 5.9 days vs. 12 ± 7.6 days, P = 0.5). Patients undergoing TT had a higher rate of all wound-healing complications (59% vs. 40%, P = 0.1) and major wound-healing complications (32% vs. 26%, P = 0.6). However, these differences were not statistically significant. No differences in major complications were identified in patients with and without preoperative radiation therapy (26% vs. 28%, P = 0.8). Fifteen per cent (n = 14) of all patients failed to heal wounds at 6 months, but only 9 per cent (n = 2) of patients undergoing TT failed to heal their wounds at 6 months compared with 17 per cent (n = 12) in the non-TT group ( P = 0.3). After controlling for important covariates, patients undergoing TT during an APR did not have a significantly lower rate of wound complications. The impact of TT on wound healing in patients with recurrent cancer and preoperative radiation therapy is suggestive of a benefit but requires prospective investigation.

How to treat the persistent perineal sinus after rectal excision

As surgery for more advanced and complex pelvic malignancies continues to expand to include larger and more exenterative techniques, dealing with the resulting pelvic and perineal defect has become an increasingly frequent necessity. The goal is both to close the defect and to accomplish complete healing. Methodology for managing the perineal wound, which results after proctocolectomy for cancer and more recently, after exenterative resection of the rectum, sacrum, uterus, vagina, bladder and larger areas of soft tissue (i.e. perineum), varies between simple closure on one hand and creation of complex gluteal and rectus abdominus flaps on the other. We examined these methodologies in terms of indications, technical details, complications and outcomes. Finally, the newest techniques for eliminating persistent perineal sinus tracts are detailed.

Surgical treatment of inflammatory bowel disease

Appropriate surgical management of Crohn disease is predicated on multiple variables, but stricturoplasty is generally reserved for small bowel disease, whereas resection is utilized in ileocolonic inflammation and favored for large bowel disease. Laparoscopic resection is becoming increasingly useful and justified for ileocolic resections, and segmental resection should be strongly considered for limited large bowel inflammation. Some centers are also using a laparoscopic approach for the surgical treatment of acute or chronic ulcerative colitis, although the benefits are less apparent. Proctocolectomy with ileostomy or ileal pouch-anal anastomosis returns the patient's quality of life to a level comparable to that enjoyed by the general population. Creation of a pouch is performed in most instances, but early complications may warrant pouch revision and later complications, such as pouchitis, can mandate pouch excision.