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Chrelias T, Berkane Y, Rousson E, Uygun K, Meunier B, Kartheuser A, Watier E, Duisit J, Bertheuil N. Gluteal Propeller Perforator Flaps: A Paradigm Shift in Abdominoperineal Amputation Reconstruction. J Clin Med 2023; 12:4014. [PMID: 37373707 DOI: 10.3390/jcm12124014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Abdominoperineal amputation (AAP) is a gold standard procedure treating advanced abdominal and pelvic cancers. The defect resulting from this extensive surgery must be reconstructed to avoid complications, such as infection, dehiscence, delayed healing, or even death. Several approaches can be chosen depending on the patient. Muscle-based reconstructions are a reliable solution but are responsible for additional morbidity for these fragile patients. We present and discuss our experience in AAP reconstruction using gluteal-artery-based propeller perforator flaps (G-PPF) in a case series. Between January 2017 and March 2021, 20 patients received G-PPF reconstruction in two centers. Either superior gluteal artery (SGAP)- or inferior artery (IGAP)-based perforator flaps were performed depending on the best configuration. Preoperative, intraoperative, and postoperative data were collected. A total of 23 G-PPF were performed-12 SGAP and 11 IGAP flaps. Final defect coverage was achieved in 100% of cases. Eleven patients experienced at least one complication (55%), amongst whom six patients (30%) had delayed healing, and three patients (15%) had at least one flap complication. One patient underwent a new surgery at 4 months for a perineal abscess under the flap, and three patients died from disease recurrence. Gluteal-artery-based propeller perforator flaps are an effective and modern surgical procedure for AAP reconstruction. Their mechanic properties, in addition to their low morbidity, make them an optimal technique for this purpose; however, technical skills are needed, and closer surveillance with patient compliance is critical to ensure success. G-PPF should be widely used in specialized centers and considered a modern alternative to muscle-based reconstructions.
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Affiliation(s)
- Theodoros Chrelias
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Yanis Berkane
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Shriners Children's Boston, Harvard Medical School, Boston, MA 02115, USA
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- MICMAC, UMR INSERM U1236, Rennes University Hospital, 35033 Rennes, France
| | - Etienne Rousson
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Korkut Uygun
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Shriners Children's Boston, Harvard Medical School, Boston, MA 02115, USA
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bernard Meunier
- Department of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Alex Kartheuser
- Colorectal Surgery Unit, Department of Surgery, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Eric Watier
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Jérôme Duisit
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
- Department of Plastic and Reconstructive Surgery, Hôpitaux IRIS Sud, 1050 Brussels, Belgium
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Shriners Children's Boston, Harvard Medical School, Boston, MA 02115, USA
- MICMAC, UMR INSERM U1236, Rennes University Hospital, 35033 Rennes, France
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DeLozier OM, Stiles ZE, Shibata D, Deneve JL, Monroe J, Dickson PV, Mathew A, Chandler RG, Behrman SW. Gracilis Flap Reconstruction After Proctocolectomy for Malignancy and Inflammatory Bowel Disease. Am Surg 2023; 89:247-254. [PMID: 33886373 DOI: 10.1177/00031348211011146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Olivia M DeLozier
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zachary E Stiles
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin Monroe
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alex Mathew
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert G Chandler
- Department of Plastic Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephen W Behrman
- Department of Surgery, 430482University of Tennessee Health Science Center, Memphis, TN, USA
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A Comparison of Perineal Myocutaneous Flaps Following Abdominoperineal Excision of the Rectum for Anorectal Pathology. Dis Colon Rectum 2022; 65:1316-1324. [PMID: 35156364 DOI: 10.1097/dcr.0000000000002271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types. OBJECTIVE To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology. DESIGN This was a retrospective comparative study. SETTING This study was conducted at a large, tertiary referral institution. PATIENTS Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded. MAIN OUTCOME MEASURES The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques. RESULTS A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05). LIMITATIONS This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size. CONCLUSION Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal. ANTECEDENTES La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.
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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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Zhang C, Yang X, Bi H. Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. BMC Surg 2022; 22:304. [PMID: 35933336 PMCID: PMC9357311 DOI: 10.1186/s12893-022-01755-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. Methods A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months. Results The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications. Conclusions A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
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Affiliation(s)
- Chen Zhang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xin Yang
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Hongsen Bi
- Department of Plastic Surgery, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Alemrajabi M, Khavanin Zadeh M, Hemmati N, Banivaheb B, Alemrajabi F, Jahanian S, Bahadoram M, Barahman M. Inferior Part of Rectus Abdominis Muscle Flap Outcomes after Abdominoperineal Resection: A Case Series Pilot Study. World J Plast Surg 2021; 10:104-110. [PMID: 34912674 PMCID: PMC8662682 DOI: 10.29252/wjps.10.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The standard surgical treatment for low rectal cancer is abdominoperineal resection (APR). Comparing to primary closure, immediate flap reconstruction has shown to have good outcomes. We aimed to assess the inferior rectus abdominis muscle flap complications after APR surgery, a new method of reconstruction. METHODS This study was conducted from 2014 to 2016 in a single center in Firoozgar Hospital, Tehran, Iran. Eighteen patients who underwent pelvic floor closure with inferior part of abdominis rectus musculofascial flap were included enrolled. The sampling method used in this study was census. All patients had distal rectoanal malignancies. A checklist including age, gender, tumor location, complications after surgery, tumor type, length of hospital stay, length of operation, neoadjuvant chemotherapy and neoadjuvant radiotherapy history was filled for all patients. RESULTS Among 18 participants, 27.8% were female. The mean age of participants was 58.28 ± 17.86 yr (minimum of 19 and the maximum of 89 yr). The pathology of the tumor in all but one of the cases was adenocarcinoma (94.4%). The overall complication rate after surgery was 27.8%. In total, 80% received neoadjuvant chemoradiotherapy. In 12 months follow-up 2 patients needed reoperation. CONCLUSION Inferior part of rectus abdominis muscle flap was a reliable and comparable means of reconstruction after APR surgery with low rate of complications and mortality.
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Affiliation(s)
- Mahdi Alemrajabi
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Morteza Khavanin Zadeh
- Hasheminejad Kidney Center (HKC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Nima Hemmati
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Behrouz Banivaheb
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Fatemeh Alemrajabi
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Sepideh Jahanian
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mohammad Bahadoram
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maedeh Barahman
- Firoozgar Clinical Research Devel-opment Center (FCRDC), Firoozgar hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
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Bhama AR, Maykel JA. Diagnosis and Management of Chronic Anastomotic Leak. Clin Colon Rectal Surg 2021; 34:406-411. [PMID: 34853562 DOI: 10.1055/s-0041-1732322] [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: 10/19/2022]
Abstract
Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.
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Affiliation(s)
- Anuradha R Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Wooster, Massachusetts
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Zeiderman MR, Nuño M, Sahar DE, Farkas LM. Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample. J Plast Reconstr Aesthet Surg 2021; 74:2085-2094. [PMID: 33455867 DOI: 10.1016/j.bjps.2020.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 12/07/2020] [Accepted: 12/19/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Flap reconstruction of radiated pelvic oncologic defects decreases perineal wound-healing complications. How widely and how often reconstructions are performed, and how technical mastery and improved perioperative care has affected outcomes, is unknown. Our objective is to 1) provide a comprehensive evaluation of national trends in flap reconstruction of pelvic oncologic defects and 2) compare complications and length of stay (LOS) in patients with/without reconstruction. METHODS The National Inpatient Sample (NIS) database was queried (1998-2014) for patients diagnosed with cancer, primarily of the rectum and anus, who underwent abdominoperineal resection (APR) or pelvic exenteration (PE). Differences in complications and LOS were compared between patients with flap reconstruction versus primary closure. Regional and hospital outcomes were also analyzed. RESULTS The cohort included 117,923 adult patients; 3,673 (3.1%) underwent flap reconstruction. Flap reconstruction rates increased from 0.8% in 1998 to 9.8% in 2014. Extirpative procedures decreased 37.4% from 1998 to 2014. Flap reconstruction decreased risk of wound breakdown (OR 0.87; p = 0.0029) and need for secondary closure of dehiscence (OR 0.82; p = 0.0023) between periods 1998-2009 and 2010-2014. Median LOS was higher for flap patients (median [IQR] of 9.8 [7.2,14.8] vs. 7.9 [6.1-11.0; p < 0.0001) and decreased over time. CONCLUSIONS The use of flap reconstruction for pelvic oncologic defects increased from 1998 to 2014, with a reduction in LOS. Following flap reconstruction, overall complications are higher, but wound breakdown and dehiscence requiring reclosure are decreasing, suggesting technique maturation. We anticipate flap reconstruction rates will increase with further improvement in patient outcomes.
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Affiliation(s)
- Matthew R Zeiderman
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA; Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA.
| | - Miriam Nuño
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA; Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA; Department of Public Health Sciences, Division of Biostatistics, University of California, Davis USA
| | - David E Sahar
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA
| | - Linda M Farkas
- Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA; Department of Surgery, Division of Colon and Rectal Surgery, University of Texas Southwestern Medical Center USA.
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Inferior Part of Rectus Abdominis Muscle Flap Outcomes after Abdominoperineal Resection: A Case Series Pilot Study. World J Plast Surg 2021. [DOI: 10.52547/wjps.10.3.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Kent I, Gilshtein H, Montorfano L, Valera RJ, Kahramangil B, Moon S, Freund MR, Newman MI, Wexner SD. Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches. Surgery 2021; 170:1342-1346. [PMID: 34144816 DOI: 10.1016/j.surg.2021.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/25/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap. METHODS This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates. RESULTS Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach. CONCLUSION Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.
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Affiliation(s)
- Ilan Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. https://twitter.com/ilan_kent
| | - Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
| | | | - Roberto J Valera
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, FL
| | - Bora Kahramangil
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, FL
| | - Savannah Moon
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, FL
| | - Michael R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL. https://twitter.com/mikifreund
| | - Martin I Newman
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, FL
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL.
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Van Vliet A, Girardot A, Bouchez J, Bigness A, Wang K, Moino D, Theodotou A, Pothuraju T, Felder S, Smith P, Kumar A, Dayicioglu D. How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction. Ann Plast Surg 2021; 86:S571-S574. [PMID: 34100815 DOI: 10.1097/sap.0000000000002875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. METHODS A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. RESULTS There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). CONCLUSIONS The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.
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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: 13] [Impact Index Per Article: 4.3] [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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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: 0.8] [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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Thiele JR, Weber J, Neeff HP, Manegold P, Fichtner-Feigl S, Stark GB, Eisenhardt SU. Reconstruction of Perineal Defects: A Comparison of the Myocutaneous Gracilis and the Gluteal Fold Flap in Interdisciplinary Anorectal Tumor Resection. Front Oncol 2020; 10:668. [PMID: 32435617 PMCID: PMC7218107 DOI: 10.3389/fonc.2020.00668] [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: 08/02/2019] [Accepted: 04/09/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction: Resection of anorectal malignancies may result in extensive perineal/pelvic defects that require an interdisciplinary surgical approach involving reconstructive surgery. The myocutaneous gracilis flap (MGF) and the gluteal fold flap (GFF) are common options for defect coverage in this area. Here we report our experience with the MGF/GFF and compare the outcome regarding clinical key parameters. Methods: In a retrospective chart review, we collected data from the Department of Plastic Surgery of the University of Freiburg from December 2008–18 focusing on epidemiological, oncological, and therapy-related data including comorbidities (ASA Classification) and peri-/postoperative complications (Clavien-Dindo-System). Results: Twenty-nine patients were included with a mean follow-up of 17 months. Of the cases, 19 (65.5%) presented with recurrent disease, 21 (72.4%) received radiochemotherapy preoperatively, 2 (6.9%) received chemotherapy alone. Microscopic tumor free margins were achieved in 25 cases (86.2%). 17 patients (7 men, 10 women, rectal adenocarcinoma n = 11; anal squamous cell carcinoma n = 6; mean age 58.5 ± 10.68, mean BMI 23.1, mean ASA score 2.8) received a MGF (unilateral n = 10; bilateral n = 7). Twelve patients (7 men, 5 women, rectal adenocarcinoma n = 7; anal squamous cell carcinoma n = 4, proctodeal gland carcinoma n = 1, mean age 66.2 ± 9.2, mean BMI 23.6, mean ASA score 2.6) received coverage with a GFF (unilateral n = 4; bilateral n = 8). Mean operation time of coverage was 105 ± 9 min for unilateral and 163 ± 11 for bilateral MGFs, 70 ± 13 min for unilateral and 107 ± 14 for bilateral GFFs. Complications affected 62%. There was no significant difference in the complication rate between the MGF- and GFF-group. Complications were mainly wound healing disorders that did not extend the hospital stay. No flap loss and no complication that lead to long-lasting disability was documented (both groups). Pain-free sitting took more time in the GFF-group due to the location of the donor site. Conclusion: MG-flaps and GF-flaps prove to be reliable and robust techniques for perineal/pelvic reconstruction. Though flap elevation is significantly faster for GF-flaps, preoperative planning and intraoperative Doppler confirmation are advisable. With comparable complication rates, we suggest a decision-making based on distribution of adipose tissue for dead space obliteration, intraoperative patient positioning, and perforator vessel quality/distribution.
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Affiliation(s)
- Jan R Thiele
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Janick Weber
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Hannes P Neeff
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Philipp Manegold
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Medical Center, University of Freiburg, Freiburg, Germany
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Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2733. [PMID: 32440406 PMCID: PMC7209827 DOI: 10.1097/gox.0000000000002733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
Background: Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration. Methods: Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate. Results: A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m2 (IQR: 24.2–26.7 kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient. Conclusions: The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.
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Alemrajabi M, Moradi S, Jahanian S, Banivaheb B, Hemmati N, Safari S. Inferior part of rectus abdominis muscle flap: A case report. Med J Islam Repub Iran 2020; 33:111. [PMID: 32002390 PMCID: PMC6983492 DOI: 10.34171/mjiri.33.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Indexed: 01/13/2023] Open
Abstract
Background: Abdominoperineal resection (APR) is the standard surgical treatment for low-lying anorectal malignancies. It seems that immediate flap reconstruction has fewer complications compared to primary closure. There are several options for local flap reconstruction of perineal wound closure, and each specific flap method has its own advantages and disadvantages.
Case presentation: In this case report, a new method of reconstruction is presented which contains only the inferior part of the rectus abdominis muscle in 2 patients, one with unilateral and the other with bilateral involvement and they both underwent APR. Both patients were referred to the colorectal surgery clinic for APR by an oncologist. Both patients had severe constipation and both reported pain on defecation and rectorrhagia. Patient 1 received a unilateral inferior part of rectus abdominis muscle flap and patient 2 received a bilateral flap.
Conclusion: Immediate flap reconstruction after APR has fewer complications than primary closure and the inferior part of rectus abdominis muscle flap seems to be a possible means of reconstruction after APR.
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Affiliation(s)
- Mahdi Alemrajabi
- Department of Surgery, Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Moradi
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Jahanian
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Behrouz Banivaheb
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Nima Hemmati
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Safari
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
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Immediate Reconstruction After Colorectal Cancer Resection: A Cohort Analysis Through the National Surgical Quality Improvement Program and Outcomes Review. Ann Plast Surg 2020; 84:196-200. [PMID: 31904642 DOI: 10.1097/sap.0000000000002103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Colorectal cancer is one of the most common and fatal malignancies in the United States. When localized to the distal gastrointestinal tract, surgical therapy includes abdominoperineal resection (APR) or pelvic exenteration (PEX). Subsequent ablative defects are considerable, impart concerning morbidity, and often necessitate autologous reconstruction. The aim of this study was to assess postoperative outcomes after reconstruction of APR and PEX defects. METHODS The American College of Surgeons National Surgical Quality Improvement Program (2005-2017) was queried for patients undergoing APR for lower gastrointestinal malignancies with concurrent autologous reconstructions. Cases of disseminated cancer were excluded. Postoperative adverse event profiles, including rates of wound and systemic complications, were evaluated. Multivariate regression analysis controlling for age, sex, body mass index, and operative time was performed to calculate adjusted odds ratios (ORs). RESULTS A total of 1309 patients were identified as undergoing APR/PEX with concomitant reconstruction. The majority (96.9%) of reconstructions consisted of muscle, myocutaneous, fasciocutaneous, or omental pedicled flaps. Of the cohort, 45.7% experienced at least 1 all-cause complication within 30-days of the procedure. Having a limited or moderate frailty (frailty index of "1" or "2") was identified as a predictor of all-cause complications [OR, 1.556; 95% confidence interval (CI), 1.187-2.040, P = 0.001; and OR, 1.741; 95% CI, 1.193-2.541, P = 0.004, respectively], whereas smoking was a predictor of wound complications (OR, 1.462; 95% CI, 1.070-1.996, P = 0.017) and steroid use was a predictor of mild systemic complications (OR, 2.006; 95% CI, 1.058-3.805, P = 0.033). CONCLUSION Anorectal cancer resection often necessitates reconstruction secondary to postexenteration perineal defects. The incidence of postoperative complications is relatively high, and several risk factors are identified to help refine patient optimization.
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Risk factors for delayed perineal wound healing and its impact on prolonged hospital stay after abdominoperineal resection. World J Surg Oncol 2019; 17:226. [PMID: 31864365 PMCID: PMC6925835 DOI: 10.1186/s12957-019-1768-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/06/2019] [Indexed: 11/23/2022] Open
Abstract
Background Perineal wound complications are a long-lasting issue for abdominoperineal resection (APR) patients. Complication rates as high as 60% have been reported, with the most common complication being delayed perineal wound healing. The aim of this study was to identify risk factors for delayed perineal wound healing and its impact on prolonged hospital stay. Methods We included low rectal tumor patients who underwent APR at a referral medical center from April 2002 to December 2017; a total of 229 patients were included. The basic characteristics and surgical outcomes of the patients were analyzed to identify risk factors for delayed perineal wound healing (> 30 days after APR) and prolonged hospital stay (post-APR hospital stay > 14 days). Results All patients received primary closure for their perineal wound. The majority of patients were diagnosed with adenocarcinoma (N = 213, 93.1%). In the univariate analysis, patients with hypoalbuminemia (albumin < 3.5 g/dL) had an increased risk of delayed wound healing (39.5% vs. 60.5%, P = 0.001), which was an independent risk factor in the multivariable analysis (OR 2.962, 95% CI 1.437–6.102, P = 0.003). Patients with delayed wound healing also had a significantly increased risk of prolonged hospital stay (OR 6.404, 95% CI 3.508–11.694, P < 0.001). Conclusions Hypoalbuminemia was an independent risk factor for delayed wound healing, which consequently led to a prolonged hospital stay. Further clinical trials are needed to reduce the incidence of delayed perineal wound healing by correcting albumin levels or nutritional status before APR.
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An Algorithmic Approach to Perineal Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2572. [PMID: 32537311 PMCID: PMC7288874 DOI: 10.1097/gox.0000000000002572] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/18/2019] [Indexed: 01/11/2023]
Abstract
Perineal wounds are one of the more challenging plastic surgical defects to reconstruct. Resections in the perineum vary in size and are frequently complicated by radiation, chemotherapy, and contamination. Furthermore, the awkward location and potential need to maintain function of the anus, urethra, and vagina and to allow comfortable sitting all contribute to the complexity of these reconstructions. In light of this complex nature, many options are available for flap coverage. In this paper, we discuss the properties of perineal defects that make each option appropriate.
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Stein MJ, Karir A, Ramji M, Allen M, Bain JR, Avram R, Boushey R, Auer R, Jarmuske M. Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection✰. J Plast Reconstr Aesthet Surg 2019; 72:565-571. [DOI: 10.1016/j.bjps.2018.12.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 12/14/2018] [Accepted: 12/21/2018] [Indexed: 11/15/2022]
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Reconstruction of Pelvic Exenteration Defects Using the Combined Method With Extended Vertical Rectus Abdominus Flap and Vacuum-Assisted Suction Drainage. Int Surg 2019. [DOI: 10.9738/intsurg-d-17-00105.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction:
Pelvic exenteration is a highly invasive procedure, with a reported rate of 20%–80% for serious complications. Thus, the prevention of postoperative complications is a major issue. Many previous reports have emphasized the importance of filling the dead space to prevent postoperative complications. In addition to filling the dead space, we believe that achieving sufficient drainage is extremely important. In this paper, we present a new combined method of the extended rectus abdominis myocutaneous flap and vacuum drainage with multiple drains, which achieved a lower frequency of complications.
Case Presentation:
The subjects were 6 patients who underwent reconstruction following pelvic exenteration during a 7-year period between April 2005 and September 2013. We retrospectively measured the volume of the pelvic cavity and that of the rectus abdominis flap on lateral computed tomography (CT) scans to calculate the percentage of the dead space that was filled by the flap. There were no problems with flap engraftment in any of the patients. There were no serious complications, and no patient required additional surgery. The percentage of the dead space filled ranged from 25% to 46% (mean: 32%).
Conclusion:
The rectus flap + vacuum drainage method, which uses an extended rectus abdominis myocutaneous flap to decrease the pelvic dead space and multiple vacuum suction drains, was associated with the prevention of serious complications.
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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: 1.2] [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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Gluteal fold flap for pelvic and perineal reconstruction following total pelvic exenteration. JPRAS Open 2018; 19:45-49. [PMID: 32158851 PMCID: PMC7061599 DOI: 10.1016/j.jpra.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/28/2018] [Accepted: 10/11/2018] [Indexed: 11/21/2022] Open
Abstract
Background The rectus abdominis myocutaneous flap has been used as the first choice for pelvic and perineal reconstruction. However, due to previous abdominal surgery and multiple stoma placements in our patients, the rectus abdominis myocutaneous flap could not be used for such reconstruction. Here, we describe the use of bilateral gluteal fold flaps for pelvic and perineal reconstruction following total pelvic exenteration to treat recurrent cervical cancer. Methods We performed three bilateral gluteal fold flap operations for perineal reconstruction in three patients between 2008 and 2011. The cause of the perineal defect was total pelvic exenteration, which was performed to treat recurrent cervical cancer in all patients. Results All flaps completely survived and there were no severe postoperative complication. Good cosmetic results were achieved in all patients. Conclusions The gluteal fold flap is a useful option for reconstructing extensive pelvic and perial defect after total pelvic exenteration because of sufficient soft tissue volume, reliable blood supply, cosmetic results and minimal donor-site morbidity.
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Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects. Dis Colon Rectum 2017; 60:945-953. [PMID: 28796733 DOI: 10.1097/dcr.0000000000000875] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN This was a prospective case series. SETTINGS This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured. RESULTS The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.
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Vertical Rectus Abdominis Myocutaneous Versus Alternative Flaps for Perineal Repair After Abdominoperineal Excision of the Rectum in the Era of Laparoscopic Surgery. Ann Plast Surg 2017; 79:101-106. [DOI: 10.1097/sap.0000000000001137] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mahmoud NN, Halwani Y, Montbrun SD, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP. Current management of perianal Crohn’s disease. Curr Probl Surg 2017; 54:262-298. [DOI: 10.1067/j.cpsurg.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/04/2017] [Indexed: 12/11/2022]
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Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2016; 137:1602-1613. [PMID: 26796372 DOI: 10.1097/prs.0000000000002107] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications. METHODS A comprehensive literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the MEDLINE, EMBASE, Google Scholar, and Cochrane Library databases. After data extraction from included studies, meta-analysis was performed to compare outcome parameters defining surgical-site complications of flap and primary closure. RESULTS Our systematic review yielded 10 eligible studies (one randomized controlled trial and nine retrospective studies) involving 566 patients (226 flaps and 340 primary closures). Eight studies described rectus abdominis myocutaneous flaps and two studies used gracilis flaps. In meta-analysis, primary closure was more than twice as likely to be associated with total perineal wound complications compared with flap closure (OR, 2.17; 95 percent CI, 1.34 to 3.14; p = 0.001). Rates of major perineal wound complications were also significantly higher in the primary closure group (OR, 3.64; 95 percent CI, 1.43 to 7.79; p = 0.005). There was no statistically significant difference between primary and flap closure for minor perineal wound complications, abdominal hernias, length of stay, or reoperation rate. CONCLUSIONS This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure for pelvic reconstruction. The authors' results have validated the use of myocutaneous flaps for reducing perineal morbidity following abdominoperineal resection or pelvic exenteration. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Sheckter CC, Shakir A, Vo H, Tsai J, Nazerali R, Lee GK. Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience. J Plast Reconstr Aesthet Surg 2016; 69:1506-1512. [DOI: 10.1016/j.bjps.2016.06.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 06/13/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
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Gentileschi S, Servillo M, Garganese G, Simona F, Scambia G, Salgarello M. Versatility of pedicled anterolateral thigh flap in gynecologic reconstruction after vulvar cancer extirpative surgery. Microsurgery 2016; 37:516-524. [DOI: 10.1002/micr.30077] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/01/2016] [Accepted: 05/13/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Stefano Gentileschi
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Maria Servillo
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Giorgia Garganese
- Department of Gynecology; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Fragomeni Simona
- Department of Gynecology; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Giovanni Scambia
- Department of Gynecology; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Marzia Salgarello
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
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Peirce C, Martin S. Management of the Perineal Defect after Abdominoperineal Excision. Clin Colon Rectal Surg 2016; 29:160-7. [PMID: 27247542 PMCID: PMC4882185 DOI: 10.1055/s-0036-1580627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.
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Affiliation(s)
- Colin Peirce
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Sean Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Predictors of wound dehiscence and its impact on mortality after abdominoperineal resection: data from the National Surgical Quality Improvement Program. Tech Coloproctol 2016; 20:475-82. [DOI: 10.1007/s10151-016-1486-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
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Goldie SJ, Almasharqah R, Fogg QA, Anderson W. Extending the use of the gracilis muscle flap in perineal reconstruction surgery. J Plast Reconstr Aesthet Surg 2016; 69:1097-101. [PMID: 27221783 DOI: 10.1016/j.bjps.2016.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/10/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
Abstract
Reconstruction of the perineum is required following oncological resections. Plastic surgical techniques can be used to restore the aesthetics and function of the perineum. The gracilis myocutaneous flap provides a substantial skin paddle, with minimal donor site morbidity. The flap is pedicled on a perforator from the medial circumflex femoral artery, giving it limited reach across the perineum. Tunnelling the flap under the adductor longus muscle may free up more of the arterial pedicle, increasing its reach. On three female cadavers, bilateral gracilis flaps were raised in the standard surgical manner, giving six flaps in total. With the flaps pedicled across the perineum, the distance from the tip of each flap was measured to the anterior superior iliac spine (ASIS). The flaps were then tunnelled under the adductor longus muscle. The distances to the ASIS were measured again. The average pedicle length was greater than 7 cm. Tunnelling the flap under the adductor longus muscle increased the reach by more than 4 cm on average. Cadaveric dissection has shown that tunnelling of the flap in a novel way increase its reach across the perineum. This additional flexibility improves its use clinically and is of benefit to plastic surgeons operating in perineal reconstruction.
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Affiliation(s)
- Stephen J Goldie
- Department of Plastic Surgery, St John's Hospital, Howden Road West, Howden, Livingston, West Lothian, Scotland, EH54 6PP, United Kingdom.
| | - Riyadh Almasharqah
- Department of Plastic Surgery, St John's Hospital, Howden Road West, Howden, Livingston, West Lothian, Scotland, EH54 6PP, United Kingdom
| | - Quentin A Fogg
- Laboratory of Human Anatomy, School of Life Sciences, University Avenue, University of Glasgow, Glasgow, Scotland, G12 8QQ, United Kingdom; Centre for Human Anatomy Education, Department of Anatomy and Developmental Biology, 19 Innovation Walk, Monash University, Melbourne, 3800, Australia
| | - William Anderson
- Department of Plastic Surgery, St John's Hospital, Howden Road West, Howden, Livingston, West Lothian, Scotland, EH54 6PP, United Kingdom
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Curran T, Poylin V, Nagle D. Real world dehiscence rates for patients undergoing abdominoperineal resection with or without myocutaneous flap closure in the national surgical quality improvement project. Int J Colorectal Dis 2016; 31:95-104. [PMID: 26315016 DOI: 10.1007/s00384-015-2377-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Perineal wound complications cause significant morbidity following abdominoperineal resection (APR). Myocutaneous flap closure may mitigate perineal wound complications though data is limited outside of specialized oncologic centers. We aim to compare rates of wound dehiscence in patients undergoing APR with and without flap closure. METHODS All patients undergoing APR in the National Surgical Quality Improvement Program between 2005 and 2013 were included. Thirty-day rate of wound dehiscence and other perioperative outcomes were compared between the flap and non-flap cohorts. Subgroup analysis was performed for propensity score-matched cohorts and those receiving neoadjuvant radiation. RESULTS Seven thousand two hundred and five patients underwent non-emergent APR [527 (7 %) flap vs. 6678 (93 %) non-flap]. Wound dehiscence occurred in 224 patients [38 (7 %) flap vs. 186 (3 %) non-flap] with 84/224 (38 %) of these reoperated. Reoperation was more common in flap patients [15 vs. 8 %; p = 0.001]. Overall morbidity was higher in flap closure [38 % flap vs. 31 % non-flap; p < 0.001]. Dehiscence was higher for flap closure in the propensity score-matched cohort [7 vs. 3 %; p < 0.001]. Flap closure was an independent predictor of dehiscence for both the overall and propensity score-matched groups. Dehiscence was not increased in patients who had neoadjuvant radiation [5.4 % flap vs. 2.6 % non-flap; p = 0.127]. CONCLUSIONS This represents the largest study of flap vs. non-flap closure following APR and the first such study from a national database. Flap closure was independently associated with increased risk of wound dehiscence in both the overall and matched cohorts. This study highlights the challenge of wound complications following APR and provides real-world generalizable data.
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Affiliation(s)
- Thomas Curran
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue Stoneman 9, Boston, MA, 02215, USA
| | - Vitaliy Poylin
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue Stoneman 9, Boston, MA, 02215, USA
| | - Deborah Nagle
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue Stoneman 9, Boston, MA, 02215, USA.
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The Partial Myocutaneous Gluteal Flap Reconstruction of Extralevator Abdominoperineal Defects in Irradiated Patients. Ann Plast Surg 2015; 74:403-7. [DOI: 10.1097/sap.0b013e318298e60d] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Elawa S, Hallböök O, Myrelid P, Zdolsek J. Intestinal obstruction following harvest of VRAM-flap for reconstruction of a large perineal defect. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2015; 2:88-91. [PMID: 27252980 PMCID: PMC4793787 DOI: 10.3109/23320885.2015.1102640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/19/2015] [Indexed: 11/22/2022]
Abstract
A patient with locally advanced adenocarcinoma of the rectum was operated with abdominoperineal resection and perineal reconstruction with a vertical rectus abdominis musculocutaneous flap. Six days postoperatively, there was herniation of the small bowel, between the anterior and posterior rectus sheaths, to a subcutaneous location.
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Affiliation(s)
- Sherif Elawa
- Department of Hand Surgery, Plastic Surgery and Burns and
| | | | | | - Johann Zdolsek
- Department of Hand Surgery, Plastic Surgery and Burns and
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Abstract
Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.
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Affiliation(s)
- Timothy F Feldmann
- Department of Surgery, University of California Irvine, Orange County, California
| | - Monica T Young
- Department of Surgery, University of California Irvine, Orange County, California
| | - Alessio Pigazzi
- Department of Surgery, University of California Irvine, Orange County, California
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Davidge KM, Raghuram K, Hofer SOP, Ferguson PC, Wunder JS, Swallow CJ, Zhong T. Impact of Flap Reconstruction on Perineal Wound Complications Following Ablative Surgery for Advanced and Recurrent Rectal Cancers. Ann Surg Oncol 2014; 21:2068-73. [DOI: 10.1245/s10434-014-3529-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Indexed: 11/18/2022]
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Perineal Wound Complications, Risk Factors, and Outcome After Abdominoperineal Resections. Ann Plast Surg 2013; 71:209-13. [DOI: 10.1097/sap.0b013e31823fac2b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Howell AM, Jarral OA, Faiz O, Ziprin P, Darzi A, Zacharakis E. How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy--primary closure or flap repair? Best evidence topic (BET). Int J Surg 2013; 11:514-7. [PMID: 23707627 DOI: 10.1016/j.ijsu.2013.05.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 04/03/2013] [Accepted: 05/14/2013] [Indexed: 11/17/2022]
Abstract
This best evidence topic was investigated according to a described protocol. The question posed was: should the irradiated perineal wound following abdominoperineal resection (APR) be closed with primary repair or a myocutaneous flap. Using the reported search 364 papers were found of which eight represented the best evidence to answer the clinical question. The conclusion drawn is that there is some limited evidence for recommending flap closure in abdominoperineal resection post radiotherapy. The best evidence available was from a systematic review of cohort studies and case series. Although no meta-analysis was performed, overall wound healing was improved using flap closure with a low frequency of flap necrosis. Other studies providing evidence were case-control series or cohort studies. Three papers prospectively compared vertical rectus abdominus muscle (VRAM) flap with primary closure; two of which demonstrated statistically significant improvement in complication rates with flap closure. Two retrospective case control series showed significant improvement in major wound complication rates in the flap group. Two studies retrospectively compared gracilis flap repair with primary closure and showed significantly lower incidence of major perineal complications. Most studies suffered from significant limitations, small sample sizes and no direct comparisons between matched groups with respect to type of anatomic flap, wound size, tumour recurrence or radiation dose. Whilst there is evidence that myocutaneous flap closure following APR in radiotherapy patients can reduce wound related complications, prospective randomized controlled trials are warranted.
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Affiliation(s)
- A M Howell
- Department of Surgery and Cancer, Imperial College London, United Kingdom
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Sinna R, Alharbi M, Assaf N, Perignon D, Qassemyar Q, Gianfermi M, Deguines JB, Regimbeau JM, Mauvais F. Management of the perineal wound after abdominoperineal resection. J Visc Surg 2013; 150:9-18. [PMID: 23434360 DOI: 10.1016/j.jviscsurg.2013.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although many options are available for the management of perineal wounds after abdominoperineal resection, ranging from direct closure to flap reconstruction, treatment remains challenging. A better understanding of the aims, drawbacks and progress in perineal wound management after abdominoperineal rectal resection can help the surgeon make better choices for each patient, but it is very difficult to propose a single, optimal, evidence-based procedure for the management of pelvic exenteration. Recent progress provided by the extralevator abdominoperineal resection technique and perforator flap concepts have changed our conception of reconstruction leading to the different technical options highlighted in this review.
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Affiliation(s)
- R Sinna
- Department of Plastic, Reconstructive and Aesthetic Surgery, Amiens University Medical Center, Hôpital Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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Chokshi RJ, Kuhrt MP, Arrese D, Martin EW. Reconstruction of total pelvic exenteration defects with rectus abdominus myocutaneous flaps versus primary closure. Am J Surg 2013; 205:64-70. [DOI: 10.1016/j.amjsurg.2012.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 04/18/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
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Abstract
The scrotal and perineal area serves a special function. It is the pelvic outlet for the gastrointestinal tract, urinary system, and sexual function. In the male, the scrotum allows testicular mobility to reduce trauma and allow optimal thermal regulation for spermatogenesis. Trauma, infection, and cancer resection create defects that require reconstruction. The reconstructive goal here is to obtain durable coverage, function, and lastly aesthetic outcome. Pedicled local and regional flaps are the mainstay for this area. Due to the special function and appearance of the scrotum, reconstructive options for total scrotal defect always fall far short of the native scrotum. On the other hand, perineal reconstruction is overall satisfactory.
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Affiliation(s)
- Nho V Tran
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
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Sahakitrungruang C, Atittharnsakul P. Colonic flap with mucosa removed: a novel technique for pelvic reconstruction after exenteration of advanced pelvic malignancy. Tech Coloproctol 2012; 16:373-8. [DOI: 10.1007/s10151-012-0865-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 07/18/2012] [Indexed: 11/28/2022]
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45
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Saleh DB, Liddington MI, Loughenbury P, Fenn CW, Baker R, Burke D. Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach. J Plast Reconstr Aesthet Surg 2012; 65:1537-43. [PMID: 22749765 DOI: 10.1016/j.bjps.2012.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Revised: 05/05/2012] [Accepted: 05/09/2012] [Indexed: 01/02/2023]
Abstract
Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery. Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41-84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.
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Affiliation(s)
- D B Saleh
- Department of Plastic Surgery, Leeds General Infirmary, Great George St., Leeds, UK.
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46
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Sahakitrungruang C, Atittharnsakul P. Sigmoid Flap: A Novel Technique for Perineal and Neovaginal Reconstruction after Abdominoperineal Resection with Near Total Vaginectomy for Locally Advanced Rectal Cancer. J Am Coll Surg 2010; 210:e5-8. [DOI: 10.1016/j.jamcollsurg.2009.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 10/09/2009] [Indexed: 10/20/2022]
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Abstract
OBJECTIVE Perineal wound complications after abdominoperineal excision (APE) for anorectal cancer represent a considerable source of morbidity for patients. Strategies to improve wound healing include reconstruction with myocutaneous flaps. This is an evidence-based review of reconstruction of pelvic defects after APE, using rectus abdominus (RAM), gracilis and gluteus maximus flaps. METHOD A Pubmed search was performed using MESH headings. RESULTS Thirty-six studies reported outcomes of interest. Five controlled studies reported improved outcomes after APE and chemoradiotherapy with RAM reconstruction and two controlled studies reported improved outcomes with gracilis reconstruction. There were seven patients with total flap loss after RAM reconstruction, in a combined 300 patients. There were eight patients with complete cutaneous necrosis after gracilis reconstruction in a combined 83 patients. CONCLUSION Data from the controlled studies support the use of myocutaneous flaps for single-stage reconstruction after APE in the presence of chemoradiotherapy. Ultimately, the choice of flap depends on the goals of reconstruction, size of the defect and the availability of donor tissue. The implications of an expanding role for radiotherapy in the treatment of low rectal cancer and radical dissection to achieve negative circumferential margins, necessitate close co-operation between colorectal and reconstructive surgeons to achieve APE with reduced wound morbidity.
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Affiliation(s)
- P J Nisar
- Department of Colorectal Surgery, St Peter's Hospital, Chertsey, Surrey, UK.
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48
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Reconstruction of Pelvic Exenteration Defects with Anterolateral Thigh–Vastus Lateralis Muscle Flaps. Plast Reconstr Surg 2009; 124:1177-1185. [DOI: 10.1097/prs.0b013e3181b5a40f] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Caricato M, Ausania F, Marangi GF, Cipollone I, Flammia G, Persichetti P, Trodella L, Coppola R. Surgical treatment of locally advanced anal cancer after male-to-female sex reassignment surgery. World J Gastroenterol 2009; 15:2918-9. [PMID: 19533817 PMCID: PMC2699013 DOI: 10.3748/wjg.15.2918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We present a case of a transsexual patient who underwent a partial pelvectomy and genital reconstruction for anal cancer after chemoradiation. This is the first case in literature reporting on the occurrence of anal cancer after male-to-female sex reassignment surgery. We describe the surgical approach presenting our technique to avoid postoperative complications and preserve the sexual reassignment.
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