Omental pedicle flaps following proctectomy: a systematic review

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.

Omentoplasty versus cecal mobilization after abdominoperineal resection: A propensity score matching analysis

BACKGROUND

Despite the minimally invasive approach and early rehabilitation, abdominal-perineal resection (APR) remains a procedure with high morbidity, notably due to postoperative trapped bowel ileus and perineal healing complications. Several surgical techniques have been described for filling the pelvic void to prevent abscess formation and ileus by trapped bowel loop.

OBJECTIVE

The aim of our study was to compare the post APR complications for cancer of two of these techniques, omentoplasty and cecal mobilization, in a single-center study from an expert colorectal surgery center.

PATIENTS

From 2012 to 2022, 84 patients were included, including 58 (69%) with omentoplasty and 26 (31%) with cecal mobilization. They all underwent APR at Bordeaux University Hospital Center.

SETTINGS

A propensity score was used to avoid confounding factors as far as possible. Patient and procedure characteristics were initially comparable.

RESULTS

The 30-day complication rate was significantly higher in the cecal mobilization group (53.8% vs. 5.2% p < 0.01), as was the rate of pelvic abscess (34.6% vs. 0% p < 0.001).

CONCLUSION

These findings suggest that, when feasible, omentoplasty should be considered the preferred method for pelvic reconstruction following APR.

Comparison of Urinary Diversion in Patients With Prostatic Fistula to Those with Localized Radiation Injury After Radiotherapy for the Treatment of Prostate Cancer

OBJECTIVE

To compare characteristics and outcomes in patients who had radiotherapy (RT) for prostate cancer (PCa) and underwent urinary diversion (UD) due to prostatic fistula (Fistula) vs localized radiation injury (Localized).

METHODS

This study was a retrospective single-institution study. Exclusion criteria included follow-up <3 months, large pelvic tumor, and surgery for cancer control. The Fistula group included fistulization outside of the urinary tract (rectal, soft tissue, thigh, pubic symphysis, and extensive necrosis surrounding the prostate). The group Localized had a multitude of problems; however, all were confined to the urinary tract. Patient characteristics, perioperative variables, and outcomes were compared between groups.

RESULTS

Sixty-nine patients were included and had UD from 2009-2022. Median age and time from RT to UD were 73 (interquartile range (IQR) 67.9, 78.1) and 7.3 (IQR 3.2, 12.5) years. There were 29 (42%) and 40 (58%) patients in the Fistula and Localized groups. The Fistula group had a higher rate of abdominal/perineal approach (62.1% vs 12.5%, P <.001), a lower rate of right colon pouch (17.2% vs 40%, P = .043), and a longer operative time (515.7 vs 414.2 minutes, P = .017). Clavien-Dindo complications ≥3 were higher in the Fistula group (44.8% vs 20%, P = .027), including a higher rate of re-operation for recurrent pelvic abscess (37.9% vs 5%, P <.001). Survival for the cohort was 85.5% and did not differ between groups.

CONCLUSION

Patients with prostate fistula after RT for PCa undergoing UD had longer, more complex operations, and higher rates of complications, notably post-operative pelvic abscesses, compared to men with localized RT injury. Long-term survival was comparable in both groups.

Clinical results after external reinforcement of colorectal anastomosis: a systematic review

OBJECTIVE

The aim of this review is to describe and assess the existing methods to cover colorectal anastomoses with biomaterials and their clinical impact in reducing anastomotic leakage (AL).

SUMMARY BACKGROUND DATA

The most serious complication in colorectal surgery is AL. Despite improvements in its diagnosis and management, AL remains an unresolved issue. To prevent its appearance and clinical consequences, different external reinforcement techniques with synthetic or biomaterials have been described.

METHODS

A systematic review search of the available literature until June 2022 was performed, looking for all literature regarding external reinforcement of colonic or colorectal anastomoses. After the review process, a classification of materials was proposed into solid and liquid materials, and an assessment of their clinical impact was performed. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA and AMSTAR Guidelines 11,12 .

RESULTS

Ninety-seven articles that fulfilled inclusion criteria, were identified and revised. Overall, 18 of the selected articles focused on human clinical trials and 79 on animal models. Only fibrin sealants, collagen patches, and omentoplasty have shown positive results in humans.

CONCLUSIONS

Fibrin sealants, collagen patches, and omentoplasty are, so far, the most studied biomaterials. However, further studies are required to confirm these findings before definite recommendations can be made.

Omentoplasty in Patients Undergoing Abdominoperineal Resection After Long-Course Chemoradiation for Locally Advanced and Locally Recurrent Rectal Cancer: A Comparative Single-Institution Cohort Study

BACKGROUND

Omentoplasty is a commonly performed procedure after abdominoperineal resection for rectal cancer, but its effectiveness to reduce pelviperineal complications is not firmly established.

OBJECTIVE

This study aimed to assess the impact of omentoplasty on postoperative outcomes after long-course (chemo) radiotherapy and abdominoperineal resection in patients with locally advanced and locally recurrent rectal cancer.

DESIGN

Retrospective cohort study.

SETTINGS

Single center.

PATIENTS

All patients with locally advanced and locally recurrent rectal cancer undergoing abdominoperineal resection after neoadjuvant (chemo)radiation in a tertiary referral center between 2008 and 2020 were retrospectively reviewed.

MAIN OUTCOME MEASURES

Multivariable logistic and linear regression analyses were performed to analyze the association between omentoplasty and pelviperineal complications, duration of nasogastric tube drainage, and length of hospital stay.

RESULTS

A total of 305 patients were analyzed, of whom 245 underwent omentoplasty (80%). Pelviperineal complications occurred in 151 patients (50%) overall, in 125 patients (51%) with omentoplasty, and in 26 patients (43%) without omentoplasty. Independent predictors of pelviperineal complications in multivariable analyses were smoking (OR 2.68; 95% CI, 1.46-4.94) and high BMI (OR 1.68; 95% CI, 1.00-2.83), but not omentoplasty (OR 1.36; 95% CI, 0.77-2.40). The mean duration of nasogastric tube drainage was longer after omentoplasty (6 vs 4 d) with a significant association in multivariable analysis (β coefficient 1.97; 95% CI, 0.35-3.59). Patients undergoing omentoplasty had a significantly longer hospital stay (14 vs 10 d), and omentoplasty remained associated with a prolonged hospital stay after adjusting for confounding (β coefficient 3.05; 95% CI, 0.05-5.74).

LIMITATIONS

Retrospective design.

CONCLUSION

Omentoplasty was not associated with a reduced risk of the occurrence of short-term pelviperineal complications after abdominoperineal resection in patients undergoing long-course (chemo)radiotherapy. Furthermore, in patients undergoing omentoplasty, prolonged duration of nasogastric tube drainage and hospital stay was observed. See Video Abstract at http://links.lww.com/DCR/C124 .

OMENTOPLASTIA EN PACIENTES SOMETIDOS A RESECCIN ABDOMINOPERINEAL DESPUS DE QUIMIORRADIOTERAPIA DE CURSO LARGO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO Y LOCALMENTE RECURRENTE ESTUDIO DE COHORTE COMPARATIVO DE UNA SOLA INSTITUCIN

ANTECEDENTES:La omentoplastía es un procedimiento que se realiza comúnmente después de la resección abdominoperineal por cáncer de recto, pero su efectividad para reducir las complicaciones pelvicoperineales no está firmemente establecida.OBJETIVO:Evaluar el impacto de la omentoplastía en las complicaciones pelvicoperineales a corto plazo y los resultados postoperatorios después quimioradioterapia de curso largo y resección abdominoperineal en pacientes con cáncer de recto localmente avanzado y localmente recurrente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Centro único.PACIENTES:Se revisaron retrospectivamente todos los pacientes con cáncer de recto localmente avanzado y localmente recurrente sometidos a resección abdominoperineal después de quimioradiación neoadyuvante en un centro de referencia de tercer nivel entre 2008 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis de regresión lineal y logística multivariable para examinar la asociación entre la omentoplastía y las complicaciones pelvicoperineales (p. ej., problemas de heridas perineales y abscesos pélvicos), la duración del drenaje por sonda nasogástrica y la duración de la estancia hospitalaria.RESULTADOS:Se analizaron un total de 305 pacientes de los cuales 245 fueron sometidos a omentoplastía (80%). Las complicaciones pelvicoperineales ocurrieron en 151 pacientes (50%) en general, y en 125 (51%) y 26 (43%) de los pacientes con o sin omentoplastía, respectivamente. Los predictores independientes de complicaciones pelvicoperineales en análisis multivariable fueron el tabaquismo (OR 2.68, IC del 95% 1.46 a 4.94) y un IMC alto (OR 1.68, IC del 95% 1.00 a 2.83), pero no la omentoplastía (OR 1.36, IC del 95% 0.77 a 2.40) . La duración media del drenaje por sonda nasogástrica fue mayor después de la omentoplastía (6 frente a 4 días) con una asociación significativa en el análisis multivariable (coeficiente β 1.97, IC del 95%: 0.35-3.59). Los pacientes que se sometieron a una omentoplastía tuvieron una estancia hospitalaria significativamente más larga (14 frente a 10 días), y la omentoplastía permaneció asociada con una estancia hospitalaria prolongada después de ajustar por factores de confusión (coeficiente β 3.05, IC del 95%: 0.05-5.74).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:La omentoplastía no se asoció con un riesgo reducido de aparición de complicaciones pelvicoperineales a corto plazo después de la resección abdominoperineal en pacientes sometidos a quimioradioterapia de larga duración. Adicionalmente, en los pacientes sometidos a omentoplastía se observó una duración prolongada del drenaje por sonda nasogástrica y la estancia hospitalaria. Consulte Video Resumen en http://links.lww.com/DCR/C124 . (Traducción-Dr. Jorge Silva Velazco ).

Bowel seromuscular flaps used to repair pelvic defects in patients undergoing reoperative surgery

BACKGROUND

Pedicled seromuscular bowel flaps may serve as an alternative for pelvic floor reconstruction when conventional omental and muscular flaps are not an option in patients undergoing reoperative abdominopelvic surgery. The aim of this study was to evaluate a unique series of bowel seromuscular flaps used to obliterate intrapelvic defects.

METHODS

We conducted a retrospective study on all patients in a single tertiary care institutional database who had undergone pelvic reconstruction with a seromuscular bowel flap from January 2006 to December 2018. The primary outcomes measured were the 30-day morbidity and mortality rates.

RESULTS

Twelve patients (6 men 6 women, median age 56.5 years [range 33-77 years]) underwent reoperative abdominopelvic surgery requiring the use of a native small or large seromuscular bowel flap to obliterate pelvic defects. The indications for surgery included chronic infections, fistulizing Crohn's disease, and cancer. In all cases, no residual omentum was available and rectus abdominis muscle flaps were not feasible due to prior operative scars. Thirty-day morbidity occurred in 5 patients (42%), and included urine leak from ureteral injury, anastomotic leak, acute kidney injury, and superficial surgical site infection. No flaps became ischemic or required removal in the postoperative setting. No mortality was recorded.

CONCLUSIONS

Bowel seromuscular flaps are a feasible and safe alternative for covering pelvic defects in patients who are undergoing reoperative surgery without the option to use traditional omental and muscular flaps.

Management of Perineal Wounds Following Pelvic Surgery

Despite advancements in understanding and technique, there remain significant challenges in the management of a complex perineal wound following pelvic surgery. Complications including wound sepsis, fistulation, persistent sinus, and herniation produce additional morbidity and health care costs. This article details the methods of optimizing patient and operative factors to mitigate this risk, alongside strategies to deal with sequelae of wound failure.

Low Concentrated Fractionalized Nanofibers as Suitable Fillers for Optimization of Structural–Functional Parameters of Dead Space Gel Implants after Rectal Extirpation

Dead space after rectal resection in colorectal surgery is an area with a high risk of complications. In this study, our goal was to develop a novel 3D implant based on composite hydrogels enriched with fractionalized nanofibers. We employed, as a novel approach in abdominal surgery, the application of agarose gels functionalized with fractionalized nanofibers on pieces dozens of microns large with a well-preserved nano-substructure. This retained excellent cell accommodation and proliferation, while nanofiber structures in separated islets allowed cells a free migration throughout the gel. We found these low-concentrated fractionalized nanofibers to be a good tool for structural and biomechanical optimization of the 3D hydrogel implants. In addition, this nano-structuralized system can serve as a convenient drug delivery system for a controlled release of encapsulated bioactive substances from the nanofiber core. Thus, we present novel 3D nanofiber-based gels for controlled release, with a possibility to modify both their biomechanical properties and drug release intended for 3D lesions healing after a rectal extirpation, hysterectomy, or pelvic exenteration.

Omentoplasty to reduce anastomotic leak in colorectal surgery: a meta-analysis

BACKGROUND

Anastomotic leaks (AL) remain a devastating complication following intestinal anastomoses resulting in increased morbidity and mortality. Wrapping the anastomosis with omentum may be protective although data are conflicting. We performed a meta-analysis to assess the effect of omentoplasty on colorectal anastomoses.

METHODS

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until August 2021. All randomized controlled trials (RCT) that reported on the use of omentoplasty in colon and rectal surgery were included. The primary outcome was rate of overall AL while secondary outcomes included clinical and radiological AL, overall reoperation and mortality. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Four RCTs were included capturing 1067 patients. The mean (SD) age of the cohort was 61.5 (±14.8) years. On random effects analysis, omentoplasty reduced rate of overall (OR 0.43, 95% CI = 0.21-0.87, p = 0.02) and clinical AL (OR = 0.35, 95% CI = 0.15-0.81, p = 0.01). However, there was no difference in radiological AL (OR = 0.77, 95% CI = 0.40-1.47, p = 0.42), overall reoperations (OR 0.48, 95% CI = 0.18-1.32, p = 0.16) or mortality (OR 0.52, 95% CI = 0.12 to-2.18, p = 0.37). On sensitivity analysis, assessing rectal anastomoses only, the results for overall AL remained similar (OR 0.28, 95% CI = 0.12-0.61, p = 0.002).

CONCLUSION

Although omentoplasty appears to reduce the rate of overall and clinical AL, the heterogeneity in the data prevents definitive recommendations from being made. Further well-designed trials are needed to investigate this technique.

A contemporary series of surgical outcomes following subtotal colectomy and/or completion proctectomy for management of inflammatory bowel disease

BACKGROUND

The main indications for emergency subtotal colectomy (SC) include management of toxic colitis, refractory haemorrhage and/or perforation. Alternatively, elective surgery is performed for those refractory to medical therapy or with evidence of multifocal dysplasia. Overall, the annual incidence of SC has fallen since the introduction of biologic therapies and we aimed to review our current practices.

METHODS

A retrospective review of inflammatory bowel disease (IBD) patients undergoing subtotal colectomy between 2013 and 2020 was performed. Medical records, operative notes, discharge summaries, histopathology reports and other supporting documents were reviewed. Indication for surgery, management of the rectum (i.e. maintenance of rectal stump, progression to completion proctectomy or IPAA formation) associated morbidity (Clavien-Dindo classification) and length of hospital stay were examined.

RESULTS

Fifty-six IBD patients underwent a subtotal colectomy. Twenty-five patients (UC 14, Crohn's 11) had an elective procedure, and 31 patients (UC 19 Crohn's 12) had an emergency/semi-urgent procedure. Interestingly, 80% (n = 25) of the emergency cohort and 68% (n = 17) of the elective cohort had a laparoscopic resection. Major morbidity (Clavien-Dindo > 2) was higher among the emergency group (39% vs. 24%). Deep surgical site infection was the commonest morbidity (13%) in the emergency group, while superficial surgical site infection was commonest in the elective cohort (20%). Overall, there was no difference in surgical re-intervention rate (13% vs 12%), and there were no perioperative mortalities. Median post-operative length of stay was shorter in the elective cohort (9 versus 13 days).

CONCLUSION

A significant proportion of IBD patients still require semi-urgent/emergency colectomy, which is associated with considerable length of stay and morbidity. The results of our study provide real-world outcomes to help counsel patients on expected outcomes.

Opportunities and Limitations of Pelvic Exenteration Surgery

PURPOSE

The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view.

METHODS

This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used.

RESULTS

A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes).

CONCLUSION

Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.

Clinical effectiveness of omental transposition in facilitating perineal wound healing after abdominoperineal resection: a systematic review

Background

Omental transposition has been used to facilitate perineal wound healing in patients undergoing abdominoperineal resection (APR). However, there is no high-level evidence supporting the effectiveness of omental transposition in this regard. This study aimed to investigate the clinical efficacy of omental transposition in facilitating perineal wound healing after APR.

Methods

In this systematic review, we systematically searched the PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases for literature regarding the topic of our study. Studies published since the inception of each database were considered for review. The outcomes of interest were the perineal wound healing rate at 1 and 3 months postoperatively, perineal wound infection rate, and perineal wound healing period.

Results

Of the 1,923 studies identified, four articles representing 819 patients (omental transposition patients, n=295) were included in the final analysis. The wound healing rates at 1 and 3 months postoperatively in the omental transposition group (68.5% and 79.7%, respectively) did not significantly differ from those in the control group (57.4% and 78.7%, respectively) (p=0.759 and p=0.731, respectively). Perineal wound infection and chronic wound complication rates, including sinus, dehiscence, and fistula rates, also did not significantly differ between the omental transposition (8% and 7%, respectively) and control (11% and 7%, respectively) groups (p=0.221 and p=0.790, respectively).

Conclusion

Our results suggest that omental transposition does not affect perineal wound healing in patients who undergo APR.

The dead space after extirpation of rectum. Current management and searching for new materials for filling

Pelvic surgeries such as extirpation of the rectum or pelvic exenteration lead to a creation of a dead space, which can be cause of complication, such as bowel obstruction, perineal hernia, abscess or hematoma. A growing incidence of complication is expected in connection with the increasing use of laparoscopic and robotic approaches or ELAPE method. Since the bone structures do not allow compression, the only way to deal with the dead space is to fill it in. Present methods provide the filling with omental or myofascial flaps. The length and the mobility of the omental flap can be the limitation. Myofascial flaps are technically more demanding and bring the complications of a donor place. Synthetic or biological meshes do not deal with dead space problematic. Modern technologies using nanomaterials offer the possibility to produce a material with specific properties for example shape, inner structure, surface, or time of degradation. The modified material could also satisfy the requirements for filling the dead space after surgeries.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Near-infrared fluorescence angiography for intra-operative assessment of pedicled omentoplasty for filling of a pelvic cavity: a pilot study

BACKGROUND

During creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion.

METHODS

All consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018-October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification).

RESULTS

Fifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12-198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3-39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9-37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2-29.7) in well perfused and 2.5 (interquartile range 1.7-4.0) in poorly perfused tissue.

CONCLUSIONS

FA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting.

Propensity Score Adjusted Comparison of Pelviperineal Morbidity With and Without Omentoplasty Following Abdominoperineal Resection for Primary Rectal Cancer

BACKGROUND

Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear.

OBJECTIVE

This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer.

DESIGN

This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding.

SETTING

The study was undertaken in 2 teaching hospitals and 1 university hospital.

PATIENTS

Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included.

MAIN OUTCOME MEASURES

The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period.

RESULTS

Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45-1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46-3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation.

LIMITATIONS

This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts.

CONCLUSION

In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918.

Omental flaps in patients undergoing abdominoperineal resection for rectal cancer

BACKGROUND

Following abdominoperineal resection (APR) for rectal cancer, perineal wound complications are common. Omental flap creation may allow for decreased morbidity. The aim of this study was to assess wound complications in rectal cancer patients undergoing APR with and without the addition of an omental flap.

METHODS

The National Surgical Quality Improvement Program Proctectomy targeted database from 2016 to 2017 was used to identify all patients undergoing APR for rectal cancer. The primary outcomes were wound complications such as superficial site infection, deep wound infection, organ space infection, and wound dehiscence.

RESULTS

There were 3063 patients identified. One hundred seventy-three (5.6%) patients underwent APR with an omental flap repair while 2890 (94.4%) patients underwent APR without an omental flap repair. Patients in both groups were similar with regard to age, gender, body mass index, American Society of Anesthesia class, and neoadjuvant cancer treatment (all p > 0.05). Patients who underwent an omental flap repair were significantly more likely to have a postoperative organ space infection (10.4% vs. 6.5%, p = 0.04). There was no significant difference in rates of superficial site infection, deep wound infection, wound dehiscence, or reoperation between the two patient groups. In multivariable analysis, omental flap creation was independently associated with organ space infection (OR 1.72, 95%CI 1.02-2.90, p = 0.04).

CONCLUSIONS

This is the largest study to evaluate omental flap use in rectal cancer patients undergoing APR. Omental flaps are independently associated with organ space infection.

Low Hartmann's procedure or intersphincteric abdominoperineal resection in the primary treatment of low rectal cancer; a survey among surgeons evaluating current practice

BACKGROUND

Low Hartmann's procedure (LHP) and intersphincteric abdominoperineal resection (iAPR) are both surgical options in the treatment of distal rectal cancer when there is no intention to restore bowel continuity. This study aimed to evaluate current practice among members of the Dutch Association of Coloproctology (WCP).

METHODS

An online survey among members of the WCP who represent 66 Dutch hospitals was conducted. The survey consisted of 15 questions addressing indications for surgical procedures and complications.

RESULTS

Surgeons from 37 hospitals (56%) responded. Thirty-six percent does not distinguish low from high Hartmann's procedures based on estimated length of the rectal remnant. Overall, iAPR was the preferred technique in 86%. If asking whether operative approach would be different in tumours at 1 cm from the pelvic floor compared to 5 cm distance, 62% stated that they would consider a different technique. The incidence of pelvic abscess after LHP was thought to be higher, equal or lower than iAPR in 36%, 36% and 21%, respectively, with the remaining respondents not answering this question.

CONCLUSIONS

The vast majority of the respondents considers iAPR as the preferred non-restorative procedure for rectal cancer not invading the sphincter complex, which contradicts with population based data from 2011.

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.

Outcomes and prognostic factors of selective lateral pelvic lymph node dissection with preoperative chemoradiotherapy for locally advanced rectal cancer

PURPOSE

The clinical significance of preoperative chemoradiotherapy (CRT) and lateral lymph node dissection (LLND) for locally advanced rectal cancer remains unclear. We have employed total mesorectal excision and selective LLND following preoperative CRT for patients with locally advanced rectal cancer. The validity of our strategy was evaluated.

METHODS

A total of 45 patients with locally advanced rectal cancer who underwent curative surgery after CRT from November 2005 to September 2016 were retrospectively analyzed. LLND was performed only for the patients with lateral lymph nodes suspected to have metastasis based on the pretreatment images.

RESULTS

Rates of 5-year overall survival (OS) and 5-year relapse-free survival (RFS) were 85.7 and 61.8%, respectively. Univariate and multivariate analyses detected only histological response (grades 2 and 3 vs. grade 1) as a significant prognostic factor for OS and local recurrence. ypN and ypStage were significant factors for RFS by univariate analysis, while no significant factor was detected by multivariate analysis. There was no significant factor for distant recurrence. In good responders (grades 2 and 3), the local recurrence rate was 0% (P = 0.006, vs. grade 1), while distant recurrence developed in 4 of 20 cases (20%, P = 0.615, vs. grade 1). There was no local recurrence in LLND (-) group regardless the histological response.

CONCLUSIONS

Although selective LLND with preoperative CRT seems effective and valid for good responders, new treatment strategy is necessary for poor responders. Therefore, development of reliable biomarkers for histological response to CRT is an urgent need.

Snapshot Study on the Value of Omentoplasty in Abdominoperineal Resection with Primary Perineal Closure for Rectal Cancer

Background

Perineal wound complications are often encountered following abdominoperineal resection (APR). Filling of the pelvic space by omentoplasty (OP) might prevent these complications, but there is scant evidence to support its routine application.

Objective

The aim of this study was to evaluate the impact of OP on perineal wound complications.

Methods

All patients undergoing APR with primary perineal closure (PPC) for non-locally advanced rectal cancer in 71 Dutch centers in 2011 were selected from a cross-sectional snapshot study. Outcomes were compared between PPC with or without OP, which was based on variability in practice among surgeons.

Results

Of 639 patients who underwent APR for rectal cancer, 477 had a non-locally advanced tumor and PPC was performed. Of those, 172 (36%) underwent OP. Patients with OP statistically more often underwent an extralevator approach (32% vs. 14%). Median follow-up was 41 months (interquartile range 22–47). There were no significant differences with or without OP in terms of non-healing of the perineal wound at 30 days (47% vs. 48%), non-healing at the end of follow-up (9% vs. 5%), pelvic abscess (12% vs. 13%) or re-intervention for ileus (5% vs. 3%). Perineal hernia developed significantly more often after OP (13% vs. 7%), also by multivariable analysis (odds ratio 2.61, 95% confidence interval 1.271–5.364; p = 0.009).

Conclusions

In contrast to previous assumptions, OP after APR with PPC appeared not to improve perineal wound healing and seemed to increase the occurrence of perineal hernia. These findings question the routine use of OP for primary filling of the pelvic space.

Electronic supplementary material

The online version of this article (10.1245/s10434-017-6273-9) contains supplementary material, which is available to authorized users.

Surgical anatomy of the right gastro-omental artery: a study on 100 cadaver dissections

PURPOSE

The gastro-omental artery (GOA) with the greater omentum (GO) is known for its high quality as a vascular graft, its resistance to infections as an omental flap and for its multiple applications in surgery. A better knowledge of anatomical variations of GO and its vascularization can improve the application in surgery and decrease complications. The purpose of this study was to measure diameters and lengths of the right GOA (RGOA) and study the interindividual variability of these anatomical structures.

METHODS

In 100 cadaveric dissections, we carried out dissection of the RGOA and of the GO. In 70 unfixed cadavers, the transillumination technique was used to identify all RGOA branches. In the remaining 30 cadavers, prepared with Winckler's solution, barium sulfate with colored latex was injected. Digital X-ray was used to measure RGOA lengths, internal diameters and the distribution of the omental branches. The gastro-omental vein was also dissected.

RESULTS

The mean proximal and distal diameters of RGOA were 2.68 (± 0.39) mm and 0.94 (± 0.24) mm, respectively. The mean length was 244.3 (± 34.4) mm. The thickness of the omentum ranged from 5 to 15.5 mm. The arteria omentalis magna, defined in this study for the fist time as the longest and widest omental branch, was present in 73.3% cases. The trans-omental arch was present in 6% cases.

CONCLUSIONS

This morphometric study allowed us to define the vascularization and the anatomical variations of RGOA and GO. This may lead to improvement of applications in surgery and decrease complications.

Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Management of the Perineal Defect after Abdominoperineal Excision

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.

Biologic Mesh Reconstruction of the Pelvic Floor after Extralevator Abdominoperineal Excision: A Systematic Review

Introduction

The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator abdominoperineal excision of the rectum (ELAPE).

Methods

A systematic search of PubMed was conducted using the search terms: “ELAPE,” “extralevator abdominoperineal excision of rectum,” or “extralevator abdominoperineal resection.” The search yielded 17 studies.

Results

Biologic mesh was used in perineal reconstruction in 463 cases. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection (n = 93), perineal sinus and fistulae (n = 26), and perineal haematoma or seroma (n = 11). There were very few comparative studies, with only one randomized control trial (RCT) identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional abdominoperineal excision of the rectum with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the groups. Other comparative studies comparing the use of biologic mesh with techniques, such as the use of myocutaneous flaps, were of low quality.

Conclusion

Biologic mesh-assisted perineal reconstruction is a promising technique to improve wound healing and has comparable complications rates to other techniques. However, there is not enough evidence to support its use in all patients who have undergone ELAPE. Results from high-quality prospective RCTs and national/international collaborative audits are required.