Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction

BACKGROUND

The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. The authors aimed to evaluate outcomes of the VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction.

METHODS

The authors conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January of 2001 and March of 2021. Our primary outcome measure included recipient and donor surgical-site occurrences (SSOs).

RESULTS

The authors identified a total of 546 patients (55% women) with a mean age of 58 years and mean body mass index of 27 kg/m 2 . Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient SSOs occurred in 38% of patients, and donor SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients, and bulge developed in 6.4% of patients. The Cox proportional hazards regression model for hernia occurrence identified age, body mass index, tobacco use (hazard ratio, 2.03; 95% CI, 1.02 to 4.04), and use as an extended VRAM flap (hazard ratio, 2.13; 95% CI, 1.04 to 4.36). The use of mesh or component separation were not independent protective factors for hernia occurrence.

CONCLUSIONS

The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor-site hernia occurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Abdominal Mesh Use in Pedicled Rectus Abdominis Flaps for Pelvic Reconstruction

Background

Rectus abdominis flap coverage of high-risk perineal wounds following extirpative pelvic procedures can result in improved perineal outcomes. However, rectus abdominis flap harvest has morbidity associated with the donor site, including hernia or bulge development. The risk-benefit profile of mesh use in this scenario is not well-defined in the literature.

Methods

We performed a retrospective chart review of all patients who underwent rectus abdominis flap coverage of pelvic defects at our institution during July 2012-January 2021. Patient characteristics and postoperative outcomes were assessed. Patients were stratified into groups based on whether mesh was used and whether primary fascial closure was achieved. Donor site outcomes were analyzed between groups.

Results

One hundred consecutive patients were included. When considering all patients in whom primary fascial closure was achieved, the use of mesh did not significantly decrease rates of hernia development. Mesh use in this setting was associated with significantly greater rates of infection, requiring procedural intervention (12% versus 0%, P = 0.044). When considering all patients in whom mesh was used, primary fascial closure was associated with decreased rates of hernia development, and this trended toward significance (16.1% versus 0.0%, P = 0.058).

Conclusions

When closing a pedicled rectus abdominis flap donor site, if primary fascial closure is achievable, the addition of mesh to reinforce the repair does not have an added benefit. Mesh use in this setting was not shown to prevent hernia or bulge development, and was found to be associated with significantly greater rates of infection, requiring procedural intervention.

Reconstruction of a septic femoral triangle fistula with a pedicled DIEP flap: A case report and mini-review

Flap-based reconstruction techniques have shown promise in preventing scar contractures and enhancing healing in fold areas by providing vascularized and thick tissue. We report a septic rupture of the superficial femoral artery treated with an arterial allograft and covered with a contralateral pedicled Deep Inferior Epigastric Artery Perforator (DIEP) flap. The patient presented favorable outcomes, including optimal healing at 8 months, with no functional limitation. A literature review also discusses alternative pedicled perforator flaps. These modern techniques present several advantages, including reliability, and can be of great interest in complex vascular surgery cases.

Outcomes of DIEP flap reconstruction after pelvic cancer surgery: A retrospective multicenter case series

BACKGROUND

Flap reconstruction is often required after pelvic tumor resection to reduce wound complications. The use of perforator flaps has been shown to reduce donor site morbidity. The purpose of this study was to evaluate the outcomes of pedicled deep inferior epigastric perforator (pDIEP) flap reconstruction.

METHODS

This was a retrospective multicenter study of patients who underwent immediate pDIEP flap reconstruction for a pelvic or perineal defect after tumor resection between November 2012 and June 2022. The primary outcome was abdominal donor site morbidity, and the secondary outcome was perineal morbidity.

RESULTS

Thirty-four patients (median age, 57.5 years) who underwent pelvic exenteration (n = 31), extralevator abdominoperineal excision (n = 2), or extended vaginal hysterectomy (n = 1) were included. The most common indications were recurrent cervical (n = 19) and anal (n = 4) squamous cell carcinoma. Twenty-nine patients (85%) had a history of radiotherapy. Only one patient (3%) had major (Clavien-Dindo ≥ III) donor site complications (surgical site infection due to tumor recurrence). Eleven patients (32%) had at least one major recipient site complication (surgical site infection [n = 1], total [n = 2] or partial [n = 1] flap loss, perineal dehiscence [n = 2], hematoma [n = 1], fistula [n = 5]). No incisional or perineal hernias were observed during follow-up. Ninety-day survival was 100%.

CONCLUSION

Pedicled DIEP flap reconstructions performed by experienced surgical teams had good outcomes for perineal or vaginal reconstruction, with low abdominal morbidity, in patients with advanced pelvic malignancies who had undergone median laparotomy. The risks and benefits of this procedure should be carefully evaluated preoperatively using clinical and imaging data.

Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection

BACKGROUND AND OBJECTIVES

Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection.

METHODS

A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space.

RESULTS

Forty-four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence.

CONCLUSIONS

The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.

Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short-term outcomes

AIM

To explore the feasibility and safety of robotic beyond total mesorectal excision (TME) surgery for primary and recurrent pelvic malignancy.

METHODS

Patients undergoing robotic beyond TME resections for primary or recurrent pelvic malignancy between July 2015 and July 2021 in a public quaternary and a private tertiary centre were included. Demographic and clinical data were recorded and outcomes analysed.

RESULTS

Twenty-four patients (50% males) were included, with a median age of 58 (45-70.8) years, and a BMI of 26 (24.3-28.1) kg/m² . Indication for surgery was rectal adenocarcinoma in nineteen, leiomyosarcoma in two, anal squamous cell carcinoma in one and combined rectal and prostatic adenocarcinoma in two patients. All patients required resection of at least one adjacent pelvic organ including genitourinary structures (n = 23), internal iliac vessels (n = 3) and/or bone (n = 2). Eleven patients had a restorative procedure. Of the 13 nonrestorative cases, nine needed perineal reconstruction with a flap. There was one conversion due to bleeding. The mean operating time was 370 (285-424) min, and the median blood loss was 400 (200-2,000) ml. The median length of stay was 16 (9.3-23.8) days. Fourteen patients (58.3%) had postoperative complications; eight of them (33.3%) were Clavien-Dindo III or more complication. Twenty-three (95.8%) patients had an R0 resection. During a median follow-up of 10 (7-23.5) months, five patients (20.8%) had systemic recurrences. No local recurrences were identified during the study period.

CONCLUSION

Implementation of robotic beyond TME surgery for primary and recurrent pelvic malignancy is feasible within a highly specialised setting.

Pelvic exenteration: a review of current issues/controversies

Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.

Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons

BACKGROUND

 Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs).

METHODS

 Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management.

RESULTS

 Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%).

CONCLUSION

 A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.

Pelvic exenteration: Pre-, intra-, and post-operative considerations

This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.

Outcomes Following Immediate Vertical Rectus Abdominis Myocutaneous (VRAM) Flap-Based Perineal Reconstruction Following Resectional Surgery For Pelvic Malignancies

BACKGROUND

Increasingly radical surgery combined with neo-adjuvant radiotherapy present a challenge for the reconstructive surgeon. The study objective was to review outcomes of Vertical Rectus Abdominis Myocutaneous (VRAM) flap-based perineal reconstruction following resectional surgery for pelvic malignancies.

METHODS

Single-centre retrospective analysis of patients undergoing immediate VRAM flap reconstruction of a perineal/pelvic defect for pelvic malignancy between July 2009 and November 2017. Primary outcome was perineal morbidity (surgical site infection (SSI), flap loss or dehiscence and perineal hernia). Secondary outcomes were length of stay and donor site morbidity (SSI, full-thickness dehiscence and incisional hernia).

RESULTS

A total of 178 patients (96 females) were included. Median age was 67 years (range 28-88). The majority were performed for locally advanced rectal adenocarcinoma (n = 122; 68.5%) and 136 (76.4%) patients had received neoadjuvant radiotherapy. Four patients had complete flap loss (2.3%), and 40 had perineal dehiscence (22.5%); however, only, 18 patients required a return to theatre during the admission for perineal-related complications (10.1%). Abdominal dehiscence occurred in six patients (3.4%). Median length of post-operative stay was 15 days (6-131). Sixty-day mortality rate was 1.1%. SSI at the midline and perineum occurred in 34 (19.1%) and 38 patients (21.3%), respectively. At 90-day post-operatively, 75.6% of perineal wounds were healed. During a median follow-up of 44.5 months, twelve, eleven and 39 patients were diagnosed with perineal, midline and parastomal hernias, respectively (6.9%, 6.2% and 21.9%).

CONCLUSIONS

It is important to have accurate knowledge of perineal and donor-site morbidity rates to allow an informed consent process.