Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience

Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis

PURPOSE/AIM

Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR.

METHODS

PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality.

RESULTS

Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49; 

CONCLUSION

We highlight the advantage of VRAM flap closure over primary closure for perineal wounds following APR. However, tailoring operative strategy based on patient and disease factors remains important in optimising outcomes.

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Key Words

• Abdominoperineal resection
• Perineal complications
• Surgical oncology
• Vertical rectus abdominis myocutaneous flap

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Affiliation(s)

Hugo C Temperley Department of Surgery, St. James's Hospital, Dublin, Ireland. Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.
Poorya Shokuhi Department of Surgery, St. James's Hospital, Dublin, Ireland
Niall J O'Sullivan Department of Surgery, St. James's Hospital, Dublin, Ireland
Benjamin Mac Curtain Department of Surgery, St John of God Subiaco Hospital, Perth, Australia
Caitlin Waters Department of Surgery, Fiona Stanley Hospital, Perth, Australia
Alannah Murray Department of Surgery, St. James's Hospital, Dublin, Ireland
Christina E Buckley Department of Plastics, St. James's Hospital, Dublin, Ireland
Maeve O'Neill Department of Surgery, St. James's Hospital, Dublin, Ireland
Brian Mehigan Department of Surgery, St. James's Hospital, Dublin, Ireland
Paul H McCormick Department of Surgery, St. James's Hospital, Dublin, Ireland
Michael E Kelly Department of Surgery, St. James's Hospital, Dublin, Ireland Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland
John O Larkin Department of Surgery, St. James's Hospital, Dublin, Ireland

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VRAM Flap for Pelvic Floor Reconstruction after Pelvic Exenteration and Abdominoperineal Excision

Due to the still large number of patients diagnosed with pelvic neoplasms (colorectal, gynecological, and urological) in advanced stages right from the initial diagnosis, surgery represents the mainstay of treatment, often implying wide, eventually multi-organ resections in order to achieve negative surgical margins. Perineal wound morbidity, particularly in extralevator abominoperineal excision, leads to complications and local infection rates of up to 40%. Strategies to reduce postoperative wound complications are being pursued to address this issue. The VRAM flap remains the gold standard for autologous reconstruction after pelvic oncological resection; it was initially designed for abdominal wall defects and later expanded for large pelvic tissue defects. The flap's application is based on its physical characteristics, including abundant tissue and a generous skin paddle, which effectively obliterates dead space after exenterations. The generous skin paddle offers good cosmetic and functional outcomes at the recipient site. This article describes the case of a patient histopathologically diagnosed with stage IIIA squamous cell carcinoma of the uterine cervix who received multimodal onco-surgical treatment. The surgical mainstay of this treatment is pelvic exenteration. Pelvic reconstruction after this major surgery was performed using a vertical flap with the rectus abdominis.

Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience

PURPOSE

Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh.

METHODS

We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021.

RESULTS

49  patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%.

CONCLUSION

Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.

Interdisciplinary aspects of abdominal and plastic surgery - what does the (abdominal) surgeon need to know?

Introduction

The aim was to reflect the established interdisciplinary aspects of general/abdominal and plastic surgery by means of a narrative review. Methods: (i) With specific references out of the medical literature and (ii) own clinical and perioperative as well as operating technical and tactical management experiences obtained in surgical daily practice, we present a choice of options for interdisciplinary cooperation that could be food of thought for other surgeons.

Content

- Decubital ulcers require pressure relieve, debridement and plastic surgery coverage, e.g., by a rotation flap plasty, V-Y flap or "tensor-fascia-lata" (TFL) flap depending on localization (sacral/gluteal defects, ischiadic tuber). - Coverage of soft tissue defects, e.g., after lymph node dissection, tumor lesions or disturbance of wound healing can be managed with fasciocutaneous or muscle flaps. - Bariatric surgery: Surgical interventions such as butt lift, tummy tuck should be explained and demonstrated in advance and performed commonly after reduction of the body weight. - Abdominoperineal rectum extirpation (APE): Holm's procedure with greater circumferential extent of resection at the mesorectum and the insertion site of the levator muscle at the anal sphicter muscle resulting in a substantial defect is covered by myocutaneous flap plasty. - Hernia surgery: Complicated/recurrent hernias or abdominal wall defect can be covered by flap plasty to achieve functional reconstruction, e.g., using innervated muscle. Thus, abdominal wall can respond better onto changes of pressure and tension. - Necrotising fasciitis: Even in case of suspicious fasciitis, an immediate radical debridement must be performed, followed by intensive care with calculated antibiotic treatment; after appropriate stabilization tissue defects can be covered by mesh graft of flap plasty. - Soft tissue tumor lesions cannot be resected with primary closure to achieve appropriate as intended R0 resection status by means of local radical resection all the time - plastic surgery expertise has to be included into interdisciplinary tumor concepts. - Liposuction/-filling: Liposuction can be used with aesthetic intention after bariatric surgery or for lipedema. Lipofilling is possible for reconstruction and for aesthetic purpose. - Reconstruction of lymphatic vessels: Lymphedema after tumor operations interrupting or blocking lymphatic drainage can be treated with microsurgical reconstructions (such as lympho-venous anastomoses, lympho-lymphatic anastomoses or free microvascular lymph node transfer). - Microsurgery: It is substantial part of modern reconstructive plastic surgery, i.e., surgery of peripheral nerves belongs to this field. For visceral surgery, it can become important for reconstruction of the recurrent laryngeal nerve. - Sternum osteomyelitis: Radical debridement (eventually, complete sternal resection) with conditioning of the wound by vacuum-assisted closure followed by plastic surgery coverage can prevent chronification, threatening mediastinitis, persisting infectious risk, long-term suffering or limited quality of life.

Summary

The presented selection of single topics can only be an excerpt of all the options for surgical cooperation in daily clinical and surgical practice.

Outlook

An interdisciplinary approach of abdominal and plastic surgery is characterized by a highly developed cooperation in common surgical interventions including various techniques and tactics highlighting the specifics of the two fields.

A Size-Based Criteria for Flap Reconstruction After Thigh-Adductor, Soft-Tissue Sarcoma Resection

BACKGROUND

Resection of soft-tissue sarcomas from the adductor compartment is associated with significant complications. Free/pedicled flaps often are used for wound closure, but their effect on healing is unclear. We compared wound complications, oncologic, and functional outcomes for patients undergoing flap reconstruction or primary closure following resection of adductor sarcomas.

METHODS

A total of 177 patients underwent resection of an adductor sarcoma with primary closure (PrC) or free/pedicled flap reconstruction (FR). Patient, tumor, and treatment characteristics were compared, as well as wound complications, oncologic, and functional outcomes (TESS/MSTS87/MSTS93). To examine the relative benefit of flap reconstruction, number needed to treat (NNT) was calculated.

RESULTS

In total, 143 patients underwent PrC and 34 had FR, 68% of which were pedicled. There were few differences in demographic, tumor, or treatment characteristics. No significant difference was found in the rate of wound complications. Length of stay was significantly longer in FR (18 days vs. PrC 8 days; p < 0.01). Oncologic and functional outcomes were similar over 5 years follow-up. Uncomplicated wound healing occurred more often in FR compared with PrC for tumors with ≥15 cm (NNT = 8.4) or volumes ≥ 800 ml (NNT = 8.4). Tumors ≤ 336 ml do not benefit from a flap, whereas those > 600 ml are 1.5 times more likely to heal uneventfully after flap closure.

CONCLUSIONS

Although flap use prolonged hospitalization, it decreased wound healing complications for larger tumors, and in all sized tumors, it demonstrated similar functional and oncologic outcomes to primary closure. Our size-based treatment criteria can help to identify patients with large adductor sarcomas who could benefit from flap reconstruction.

LEVEL OF EVIDENCE III

(Retrospective cohort study).

Analysis of clinical and patient-reported outcomes in post-ELAPE perineal reconstruction with IGAP flap – A 5-year review

Background: Extralevator abdominoperineal excisions (ELAPE) are now the accepted treatment option for low rectal cancers, which result in large perineal defects necessitating reconstruction. The aim of our study was to assess the clinical outcomes as well as the quality-of-life parameters (QOLP) following these reconstructions. Methods: A series of 27 patients who underwent ELAPE and immediate reconstruction with inferior gluteal artery perforator flaps (IGAP) between December 2013 to December 2018 were retrospectively analysed on patient demographics, disease and treatment, complications, and QOLP. Results: With a mean age of 71.6 years, all patients had low rectal cancers and underwent ELAPE (24 open, 3 lap-assisted) and immediate IGAP flap reconstruction. The follow-up period was 1 year. The overall perineal early minor complication rate was 25.9% and the early major complication rate of 14.8%. QOLP, such as tolerance to sit, perineal pain, perineal aesthetics, showed high patient satisfaction of 77.7%, 40.74%, and 66.6%, respectively at 1 year. The perineal hernia rate was 14.8% with all patients being female (p 0.0407; significant). Conclusion: IGAP flaps are a reliable option for reconstructing post-ELAPE defects with good patient satisfaction and outcomes.

Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis

Simple Summary

The rate of perineal complications after abdominoperineal reconstruction for the treatment of cancers ranges from 25% to 60% in the literature. It is well-established in current literature that direct closure has a higher complication rate than closure with a flap. Several reconstructive options have been proposed to fill the dead space with well-vascularized tissue. Every surgeon would like to be comfortable in selecting which flap has superiority in terms of surgical outcome. In the absence of a meta-analysis on the subject due to the scarcity of RCT and comparative studies, we used a proportional meta-analysis to analyze the surgical outcomes after reconstruction with either VRAM flap or gracilis flap following oncologic resection of the vulvo-perineal region.

Abstract

Pelvic exenteration and abdominoperineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy with high morbidity due to large pelvic defects. Flaps can help provide healthy, well-vascularized, non-irradiated tissues to fill pelvic dead space. We conducted a proportional meta-analysis to compare surgical outcomes of vertical rectus abdominus myocutaneous flap (VRAM) vs. gracilis flap for vulvo-perineal reconstruction following oncologic resection. A comprehensive literature search was conducted in the MEDLINE, PubMed, Embase, Google Scholar, and Cochrane Library databases. Proportional meta-analysis was performed to compare the surgical outcomes of using VRAM or gracilis flaps. Our review yielded 16 eligible studies. The pooled resolution rate of overall donor site complications for VRAM flap (pooled proportion = 0.576 [95% CI 0.387, 0.754]) was significantly higher than the pooled rate of overall donor site complications of gracilis flap (pooled proportion = 0.160 [95% CI 0.058, 0.295]). Partial and total flap necrosis were similar in both groups. There was no statistically significant difference between minor and major complications for both flaps. Both flaps can be used safely for vulvo-perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.

Best Solutions for Perineal and Pressure Sore Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand variations of the myocutaneous rectus abdominis muscle flap as it is used for perineal reconstruction and discuss common and alternative options for perineal defect reconstruction. 2. Review primary options and alternatives to pressure sore reconstruction if the primary option is not available and recognize when pressure sore reconstruction is not feasible. 3. Highlight pertinent anatomy and techniques for the flaps described.

SUMMARY

Perineal reconstruction following tumor resection is often complicated by irradiated tissue and multiple comorbidities, making reconstruction challenging. Management of these conditions can have complication rates as high as 66 percent, which further compounds the costs and implications of managing these wounds. These complication rates can be significantly decreased using flap closure rather than primary closure. Pressure ulcers also occur in patients with poor overall health, multiple comorbidities, and often numerous prior failed reconstruction attempts. Comprehensive management of pressure sores is a significant burden to the health care system, at a cost of $9.1 to $11.6 billion per year. There exists an extensive body of literature describing the pathophysiology and management strategies for these problems. The focus of this article is to discuss best solutions for perineal and pressure ulcer reconstruction, and to explore alternative options for reconstruction.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction

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.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods

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.

Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis

AIM

Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE.

METHOD

The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed.

RESULTS

A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75).

CONCLUSION

Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

BACKGROUND

 Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications.

METHODS

 A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed.

RESULTS

 Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm². The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications.

CONCLUSION

 In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

PERINEAL REPAIR AFTER ABDOMINOPERINEAL EXCISION WITH RECTUS ABDOMINIS MYOCUTANEOUS FLAP

Background:

Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction.

Aim:

To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction

Method:

To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap.

Results:

This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion.

Conclusion:

Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina.

Versatility of Rectus Abdominis Myocutaneous Flap in Primary Reconstruction of Defects in Surgical Oncology

With the advent of microvascular surgery, the choice of reconstruction following resection of the primary has an important bearing on the final functional and cosmetic outcome in surgical oncology. The vertical rectus abdominis myocutaneous (VRAM) flap is arguably the most widely used and versatile flap in reconstructive surgery. All patients undergoing a VRAM flap reconstruction following resection of their tumor in the Surgical Oncology Department of a tertiary cancer center from 2012 to 2019 were included in the study. Defects ranged from the breast (40), head and neck (10), groin (3), and perineum (5). The primary outcome measure was incidence of complete and partial flap necrosis, while incidence of hematoma, seroma, incisional hernia, wound dehiscence, and infection were secondary outcomes measured. The patients were followed up for a minimum period of 1 year. The incidence of complete flap necrosis was 5.1% (3) and partial loss 12% (7). Incidence of minor complications such as seroma was 13.7% (8), hematoma 6.8% (4), wound dehiscence 10.3% (6), and wound infection 5.1% (3). Incisional hernia and donor site wound-related complications were not seen in any. On binary regression analysis, the presence of diabetes mellitus, smoking, and the use of adjuvant treatment were associated significantly with increased odds of flap loss. This study demonstrates the versatility and reliability of the VRAM flap in primary reconstruction of defects in surgical oncology. Optimization of risk factors such as diabetes, smoking, and weight gain can reduce flap loss and improve outcomes.

Factors associated with the use of vertical rectus abdominus myocutaneous flap reconstruction following abdominoperineal resection for anorectal cancer

BACKGROUND AND OBJECTIVES

Following abdominoperineal resection (APR), primary closure of the perineal defect is often possible. Some patients, however, require flap reconstruction. Identifying these patients preoperatively is critical to facilitate comprehensive patient counseling and optimize surgical efficacy.

METHODS

A retrospective review of patients undergoing APR over a 10-year period was performed to identify predictive factors for patients requiring reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap as opposed to primary closure. Student's t and Fisher's exact tests were utilized for statistical analysis.

RESULTS

A total of 158 patients underwent APR, 29 of whom (18%) required a VRAM flap. A higher average skin resection area was seen among those requiring flap reconstruction (P < .0001). Flap reconstruction was also associated with current smoking status (P = .0197), anal tumor location (P < .0001), and neoadjuvant radiation (P = .0457). Although not statistically significant, average tumor diameter was larger in the VRAM flap group compared with the primary closure group.

CONCLUSIONS

While the appropriate method of closure for those undergoing APR should be considered on an individual case basis, patients who smoke, have a tumor located at the anus, or require large skin resection are more likely to need flap reconstruction.

Simultaneous stoma reinforcement and perineal reconstruction with biological mesh - A multicentre prospective observational study

Introduction

The optimal method for perineal reconstruction after extralevator abdominoperineal excision (elAPE) for low rectal cancer remains controversial. This study aimed to assess whether simultaneous perineal reconstruction and parastomal reinforcement with Strattice™ Reconstructive Tissue Matrix after elAPE could prevent hernia formation.

Methods

In this prospective, multicentre, observational, non-comparative study of consecutive patients undergoing elAPE for low rectal cancer underwent simultaneous perineal reconstruction and colostomy site reinforcement with Strattice™ mesh. All patients underwent long course chemoradiotherapy prior to surgery and had excision of the coccyx. Patients were assessed for perineal wound healing at 7 day, 1, 3, 6 and 12 months, perineal and parastomal hernia defects on clinical and radiological assessment at 1 year following surgery.

Results

19 patients (median age = 67 years, median BMI = 26, M:F = 11:8) were entered the study. 10 (52.6%) patients underwent laparoscopic elAPE. The median length of post-operative stay was 9 days. Complete wound healing was observed for 8(42%) patients at 1 month, 12(63%) at 3 months, and 19(100%) patients at 12 months. Median time for radiological and clinical assessment for hernias was 12 months. No perineal hernia was detected in 17 patients following CT assessment. Dynamic MRI was undertaken in 11 patients at 12 months and all showed no evidence of perineal hernia. 3 (16%) patients had a parastomal hernia detected radiologically. No mesh was removed during the 12 months follow up period.

Conclusion

Perineal and parastomal reconstruction with biological mesh is a feasible approach for parastomal and perineal hernia prevention after laparoscopic and open elAPE.

•

In this case series, consecutive patients underwent simultaneous perineal reconstruction and colostomy site reinforcement with Strattice™ biological mesh.

•

Simultaneous perineal and parastomal reconstruction with Strattice™ mesh is an effective method of hernia prevention after elAPE.

•

High quality prospective RCTs and national/international collaborative audits are required to compare this technique with others for perineal reconstruction.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement

BACKGROUND

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE).

METHODS

A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations.

RESULTS

Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications.

CONCLUSION

This position statement updates clinicians on current evidence around perineal closure after APE surgery.

Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer

AIM

To introduce a novel, modified primary closure technique of laparoscopic extralevator abdominal perineal excision (LELAPE) for low rectal cancer.

METHODS

We retrospectively analyzed data from 76 patients with rectal cancer who underwent LELAPE from March 2013 to May 2016. Patients were classified into the modified primary closure group (32 patients) and the biological mesh closure group (44 patients). The total operating time, reconstruction time, postoperative stay duration, total cost, postoperative complications and tumor recurrence were compared.

RESULTS

All surgery was successfully performed. The pelvic reconstruction time was 14.6 ± 3.7 min for the modified primary closure group, which was significantly longer than that of the biological mesh closure group (7.2 ± 1.9 min, P < 0.001). The total operating time was not different between the two groups (236 ± 20 min vs 248 ± 43 min, P = 0.143). The postoperative hospital stay duration was 8.1 ± 1.9 d, and the total cost was 9297 ± 1260 USD for the modified primary closure group. Notably, both of these categories were significantly lower in this group than those of the biological mesh closure group (P = 0.001 and P = 0.003, respectively). There were no differences observed between groups when comparing other perioperative data, long-term complications or oncological outcomes.

CONCLUSION

The modified primary closure method for reconstruction of the pelvic floor in LELAPE for low rectal cancer is technically feasible, safe and cost-effective.

Extralevator abdominoperineal excision for rectal cancer with biological mesh for pelvic floor reconstruction

Goal

To share our experience of extra-levator abdominoperineal excision (ELAPE) for low rectal cancer, focusing on perineal repair with biological mesh.

Methods

We retrospectively analyzed medical records of all patients with low rectal cancer who underwent the ELAPE procedure using biological mesh for perineal repair at the Gastrointestinal Surgery of Nanjing Drum Power Hospital between January 2013 and September 2015. All patients were closely followed up to now.

Results

A total of 17 patients underwent ELAPE for low rectal cancer was screened. Of these, 15 patients had primary rectal cancer, 1 had local recurrent rectal cancer, and 1 had malignant melanoma. All patients underwent ELAPE successfully without intestinal perforation and got stage I healing in perineum wound without incision infection, dehiscence, cystocele perinealis, urethral dysfunction or intestinal obstruction. Perineum wound hematoma developed in just one patient and had successful percutaneous drainage in one week. During the follow-up, there was no recurrence, perineal hernia, sexual dysfunction, urinary retention, or bowel obstruction. Two patients described slight pain in the sacrococcygeal region without special handling.

Conclusion

ELAPE is applicable to low rectal cancer. Biological mesh reconstruction of perineal defect seems to be safe and effective, with high patient compliance.

The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer

BACKGROUND

Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds.

METHODS

Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded.

RESULTS

Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01).

CONCLUSIONS

Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction after Extralevator Abdominoperineal Excision: Application for Reconstruction of the Pelvic Floor and Creation of a Neovagina

BACKGROUND

The extralevator abdominoperineal excision (ELAPE) procedure creates an extensive soft tissue defect of the pelvic floor. It has been suggested that primary reconstruction reduces the risk of wound infection and delayed wound healing in this high-risk area. Use of myocutaneous flaps or omentoplasty are associated with functional limitations and complications. We performed the perineal variant of the lotus petal flap, which was originally described for vulvar reconstruction. We aimed to verify if application of the lotus petal flap in pelvic floor reconstruction after ELAPE meets the goals of an ideal reconstruction.

METHODS

We performed a retrospective study of 28 patients who underwent the lotus petal flap procedure for pelvic floor reconstruction after ELAPE between January 2011 and March 2014.

RESULTS

Median age was 62.1 years and 78.6 % of patients were female. In most patients the tumor was preoperatively irradiated (89.3 %) and in 28.6 % of the reconstructions a biological mesh was applied. No total flap loss occurred. Six (21.4 %) patients had no complications, while 13 (46.4 %) patients had minor complications (Clavien-Dindo grade I-II). Reoperation (Clavien-Dindo grade IIIb) was performed in nine patients (32.1 %), three of whom required a second lotus petal flap reconstruction. Median time until wound healing was 14 weeks. No additional surgery was performed for aesthetic problems.

CONCLUSIONS

Reconstruction of the pelvic floor after ELAPE using the fasciocutaneous lotus petal flap has limited major complications, but still with a high incidence of minor wound complications. This retrospective cohort study shows limited consequences on form and function.

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.

Intestinal obstruction following harvest of VRAM-flap for reconstruction of a large perineal defect

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.

Negative pressure wound therapy in complex trauma of perineum

OBJECTIVE

To review the experience (2011 and 2012) of Wound Center of Plastic Surgery Service, Clinics Hospital, Faculty of Medicine, University of São Paulo, with treatment of complex traumatic wounds in the perineal region with the association of negative pressure wound therapy followed by a surgical skin coverage procedure.

METHODS

This was retrospective analysis of ten patients with complex wound in the perineum resulting from trauma assisted by the Department of Plastic Surgery in HC-USP. Negative pressure was used as an alternative for improving local conditions, seeking definitive treatment with skin grafts or flaps.

RESULTS

Negative pressure was used to prepare the wound bed. In patients, the mean time of use of negative pressure system was 25.9 days, with dressing changes every 4.6 days. After negative pressure therapy, 11 local flaps were performed in nine patients, with fasciocutaneous anterolateral thigh flap used in four of these. Mean hospital stay was 58.2 days and accompaniment in Plastic Surgery was 40.5 days.

CONCLUSION

The use of negative pressure therapy led to improvement of local wound conditions faster than traditional dressings, without significant complications, proving to be the current best alternative as an adjunct for the treatment of this type of injury, always followed by surgical reconstruction with grafts and flaps.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review

PURPOSE

Extra-levator abdominal perineal excision of rectum (eLAPE) for low rectal tumours is associated with a lower incidence of circumferential resection involvement. However, there is no consensus on the ideal technique for perineal reconstruction following eLAPE. We thereby conducted a 5-year review of perineal closure outcomes following eLAPE.

METHODS

A systematic review of the literature was conducted between 2006 and July 2012. Perineal wound healing and complications in the post-operative period were examined.

RESULTS

Original data following eLAPE were found in 27 studies involving 963 individuals to inform a qualitative synthesis. Pooled analysis revealed that investigators most commonly employed either biomesh closure (12 studies, n = 149), myocutaneous flap closure (9 studies, n = 201) and primary closure (4, n = 578). The incidence of minor and major wound complications and perineal hernias across the latter groups was (27.5, 13.4 and 2.7 %), (29.4, 19.4 and 0 %) and (17.1, 6.4 and 1.2 %), respectively. Two studies utilised synthetic mesh closure (n = 4) and omentoplasty (n = 31). Objective assessment of wound healing was strikingly deficient across most studies, largely due to low level retrospective evidence lacking randomised controls. Modest cohort sizes with short follow-up data were evident due to the relative novelty of eLAPE.

CONCLUSION

The paucity of high quality data, suggests that a prospective, randomised trial is needed to determine the ideal technique for perineal reconstruction following eLAPE.

Prone cylindrical abdominoperineal resection with subsequent rectus abdominis myocutaneous flap reconstruction performed by a colorectal surgeon

PURPOSE

Prone cylindrical abdominoperineal resection (APR) leads to reduced circumferential resection margin (CRM) involvement but is associated with a large perineal deficit. A rectus abdominis myocutaneous (RAM) flap can reduce the morbidity associated with the perineal wound. This is often performed in coordination with a plastic surgeon. We reviewed the outcome of prone APR carried out by a single colorectal surgeon using RAM flap without the involvement of plastic surgeons in a district general hospital.

METHODS

Data were reviewed retrospectively for consecutive patients who have undergone prone cylindrical APR and RAM flap reconstruction between 2008 and 2011. Additional data were reviewed for all patients who have undergone supine APR between 2004 and 2008 for comparison.

RESULTS

Twelve patients (seven females, five males) of median age of 69 years (range 50-84 years) underwent prone APR and RAM flap reconstruction. The CRM was negative in all cases. One patient had complete flap necrosis and subsequent flap removal, and three (25 %) patients experienced delayed flap healing. One patient died from bronchopneumonia following a cerebrovascular accident at day 14. In the preceding 4 years, nine patients (three females, six males) of median age of 70 years (range 32-83 years) underwent supine APR alone. The CRM was negative in all cases. Three patients suffered breakdown of the perineal wound requiring prolonged packing, and one developed a methicillin-resistant Staphylococcus aureus wound infection.

CONCLUSIONS

Prone APR and RAM flap reconstruction can be performed by colorectal surgeons in a district general setting with good outcomes, without the need for a plastic surgeon, thus increasing the feasibility of this treatment modality.

Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review

AIM

An improvement in oncological outcome has been reported following an extralevator approach to abdominoperineal excision (ELAPE) for low rectal carcinoma. A larger perineal defect following ELAPE and the impact of neoadjuvant radiotherapy are sources of considerable morbidity for patients. We report an evidence-based systematic review of published data on the outcome of perineal reconstruction following ELAPE for low rectal carcinoma, comparing the use of tissue flap and biological mesh techniques.

METHOD

A literature search was performed of electronic databases including the Medline, Embase and Scopus databases (1995-2011). Studies describing outcomes relating to the perineum following ELAPE were included for review.

RESULTS

Eleven small cohort studies reported the outcome relating to the perineum following ELAPE. Pooled-analysis of 255 combined patients undergoing flap repair and 85 undergoing biological mesh repair showed no significant difference in the rates of perineal wound complications or perineal hernia formation.

CONCLUSION

There is little information on the optimal technique of perineal wound closure following ELAPE. With the limited data available, there was no significant difference in complication rates between biological mesh and flap repair. There is a need for high-quality prospective trials to compare methods of reconstruction to determine the long-term results, quality of life and function.