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Annals of Surgical Oncology

, Volume 25, Supplement 3, pp 836–837 | Cite as

ASO Author Reflections: Omentoplasty to Improve Perineal Wound Healing After Abdominoperineal Resection

  • Robin D. BlokEmail author
  • Pieter J. Tanis
Open Access
ASO Author Reflections
  • 118 Downloads

Past

Abdominoperineal resection (APR) for rectal cancer often is complicated by perineal wound problems.1 Some surgeons advocate an omentoplasty to obliterate the pelvic dead space and prevent the small bowel from descending into the pelvis.2,3 Despite the fact that globally many surgeons routinely construct omentoplasty as part of the APR, only a few small studies support the putative clinical benefits.4 This study aimed to evaluate whether omentoplasty reduces early and late perineal complications for patients treated by APR for rectal cancer in a nationwide setting.

Present

At the population level, no differences in perineal wound healing were observed between patients submitted to omentoplasty and those who were not.5 Particularly, patients experienced similar rates of pre-sacral abscess formation and a similar need for reoperation to remove small bowel obstruction in the pelvic cavity. To the contrary, omentoplasty was found to be associated with perineal herniation. This may be explained by the fact that a bulky omentum with a long vascular pedicle exerts more pressure on the perineal scar than a few loops of small bowel with restricted mesenteric length. If confirmed, these findings suggest that perhaps application of omentoplasty for primary filling of the pelvic dead space after APR should be omitted.

Future

A potential explanation for the inefficacy of omentoplasty in its current nonstandardized and non-quality-controlled application may be related to insufficient obliteration of the pelvic cavity due to inadequate mobilization of the omentum or an insufficient amount of omental fat available. Another reason might be partial ischemia of the omentum after mobilization, leading to partial necrosis and abscess formation of the omentum itself. Therefore, prospective cohort studies should focus on confirming the adequacy of pelvic filling (e.g., by postoperative imaging) and perfusion (e.g., by fluorescence angiography), with subsequent correlation with perineal wound healing. In addition, the technical way to achieve an omentoplasty with optimal filling and perfusion (e.g., left or right gastroepiploic pedicle, tunneling through transverse mesocolon or along the paracolic gutter) also must be determined. If a specific technique of omentoplasty is suggested to have an impact on perineal wound healing, this might subsequently be tested using a randomized study design. Until then, APR without omentoplasty can be considered the standard of care.

Notes

Disclosure

There are no conflicts of interest.

References

  1. 1.
    Musters GD, Klaver CEL, Bosker RJI, et al. Biological mesh closure of the pelvic floor after extralevator abdominoperineal resection for rectal cancer: a multicenter randomized controlled trial (the BIOPEX-study). Ann Surg. 2017;265:1074–81.CrossRefGoogle Scholar
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    Hultman CS, Sherrill MA, Halvorson EG, et al. Utility of the omentum in pelvic floor reconstruction following resection of anorectal malignancy: patient selection, technical caveats, and clinical outcomes. Ann Plast Surg. 2010;64:559–62.Google Scholar
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    Oida T, Kawasaki A, Mimatsu K, et al. Omental packing with continuous suction drainage following abdominoperineal resection. Hepatogastroenterology. 2012;59:380–3.Google Scholar
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    Killeen S, Devaney A, Mannion M, Martin ST, Winter DC. Omental pedicle flaps following proctectomy: a systematic review. Colorectal Dis. 2013;15:e634–45.CrossRefGoogle Scholar
  5. 5.
    Blok RD, Musters GD, Borstlap WAA, et al. Snapshot study on the value of omentoplasty in abdominoperineal resection with primary perineal closure for rectal cancer. Ann Surg Oncol. 2018;25:729–36.  https://doi.org/10.1245/s10434-017-6273-9 CrossRefGoogle Scholar

Copyright information

© The Author(s) 2018

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Department of SurgeryAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
  2. 2.LEXOR, Centre for Experimental and Molecular Medicine, Oncode Institute, Cancer Centre AmsterdamAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands

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