Rectus Flap Reconstruction Decreases Perineal Wound Complications After Pelvic Chemoradiation and Surgery: A Cohort Study
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A major source of morbidity after abdominoperineal resection (APR) after external beam pelvic radiation is perineal wound complications, seen in up to 66% of cases. Our purpose was to determine the effect of rectus abdominus myocutaneous (RAM) flap reconstruction on perineal wound morbidity in this population.
The study group consisted of 19 patients with anorectal cancer treated with external beam pelvic radiation followed by APR and RAM flap reconstruction of the perineum. A prospectively collected database was queried to identify a control group (n = 59) with anorectal cancer treated with similar radiation doses that subsequently underwent an APR without a RAM flap during the same time period. Comparison of percentages was performed with a two-sided Fisher’s exact test, and comparison of means was performed with Wilcoxon’s test.
Perineal wound complications occurred in 3 (15.8%) of the RAM flap patients and 26 (44.1%) of the control patients (P = .03). The incidence of other complications was not different between groups (42.1% vs. 42.4%; P = .8). Despite an increased number of anal squamous tumors, an increased vaginectomy rate, increased use of intraoperative radiotherapy, and an increased proportion of cases with recurrent disease, the flap group had a significantly lower rate of perineal wound complications relative to the control group.
Perineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.
KeywordsRectal cancer Perineal wound Radiotherapy Rectus abdominus myocutaneous flap
- 1.Pearlman, NW, Stiegmann, GV, Donohue, RE 1989Extended resection of fixed rectal cancerCancer63243841Google Scholar
- 2.Nilsson, PJ, Svensson, C, Goldman, S, Glimelius, B 2002Salvage abdominoperineal resection in anal epidermoid cancerBr J Surg8914259Google Scholar
- 4.Radice, E, Nelson, H, Mercill, S, Farouk, R, Petty, P, Gunderson, L 1999Primary myocutaneous flap closure following resection of locally advanced pelvic malignanciesBr J Surg8634954Google Scholar
- 5.Tompkins, RG, Warshaw, AL 1985Improved management of the perineal wound after proctectomyAnn Surg2027605Google Scholar
- 6.Anthony, JP, Mathes, SJ 1990The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closureArch Surg12513716discussion 1376–7Google Scholar
- 8.Baird, WL, Hester, TR, Nahai, F, Bostwick, J,III 1990Management of perineal wounds following abdominoperineal resection with inferior gluteal flapsArch Surg12514869Google Scholar
- 9.Jain, AK, DeFranzo, AJ, Marks, MW, Loggie, BW, Lentz, S 1997Reconstruction of pelvic exenterative wounds with transpelvic rectus abdominis flaps: a case seriesAnn Plast Surg3811522discussion 122–3Google Scholar
- 11.Bostwick, J,III, Moore, J, McGarity, WC 1988Inferior gluteal musculocutaneous flap for the obliteration of acute and chronic proctocolectomy defectsSurg Gynecol Obstet16616970Google Scholar
- 12.Ryan, JA,Jr. 1984Gracilis muscle flap for the persistent perineal sinus of inflammatory bowel diseaseAm J Surg1486470Google Scholar
- 13.Shaw, A, Futrell, JW 1978Cure of chronic perineal sinus with gluteus maximus flapSurg Gynecol Obstet14741720Google Scholar
- 15.McCraw, JB, Massey, FM, Shanklin, KD, Horton, CE 1976Vaginal reconstruction with gracilis myocutaneous flapsPlast Reconstr Surg5817683Google Scholar
- 16.Anderson, R, Turnbull, RB,Jr. 1976Grafting the unhealed perineal wound after coloproctectomy for Crohn diseaseArch Surg1113358Google Scholar
- 17.Buchel, EW, Finical, S, Johnson, C 2004Pelvic reconstruction using vertical rectus abdominis musculocutaneous flapsAnn Plast Surg52226Google Scholar
- 18.Loessin, SJ, Meland, NB, Devine, RM, Wolff, BG, Nelson, H, Zincke, H 1995Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flapsDis Colon Rectum389405Google Scholar
- 19.Pursell, SH, Day, TG,Jr, Tobin, GR 1990Distally based rectus abdominis flap for reconstruction in radical gynecologic proceduresGynecol Oncol372348Google Scholar
- 20.Mixter, RC, Wood, WA, Dibbell, DG,Sr. 1990Retroperitoneal transposition of rectus abdominis myocutaneous flaps to the perineum and backPlast Reconstr Surg8543741Google Scholar
- 21.Kroll, SS, Pollock, R, Jessup, JM, Ota, D 1989Transpelvic rectus abdominis flap reconstruction of defects following abdominal-perineal resectionAm Surg556327Google Scholar
- 22.Giampapa, V, Keller, A, Shaw, WW, Colen, SR 1984Pelvic floor reconstruction using the rectus abdominis muscle flapAnn Plast Surg13569Google Scholar
- 23.Shukla, HS, Hughes, LE 1984The rectus abdominis flap for perineal woundsAnn R Coll Surg Engl663379Google Scholar
- 24.Cordeiro, PG, Pusic, AL, Disa, JJ 2002A classification system and reconstructive algorithm for acquired vaginal defectsPlast Reconstr Surg110105865Google Scholar
- 25.Hoff, JM, Skibber, PM, Minsky, BD 2001
Cancer of the rectumDeVita, VT HSRosenberg, SA eds. Cancer: Principles and Practice of OncologyLippincott Williams & Wilkins Philadelphia3235Google Scholar
- 26.Liebermann-Meffert, D 2000The greater omentum: anatomy, embryology, and surgical applicationsSurg Clin North Am8027593Google Scholar
- 27.Topor, B, Acland, RD, Kolodko, V, Galandiuk, S 2001Omental transposition for low pelvic anastomosesAm J Surg1824604Google Scholar