Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer

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Abstract

Background

Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR.

Methods

Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures.

Results

Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35–44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8–12 days).

Conclusions

The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.

Electronic supplementary material

The online version of this article (10.1007/s10151-019-02055-1) contains supplementary material, which is available to authorized users.

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Most cited references 22

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Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.

Gijsbert Musters, Christianne J. Buskens, Willem Bemelman … (2014)

Impaired perineal wound healing has become a significant clinical problem after abdominoperineal resection for rectal cancer. The increased use of neoadjuvant radiotherapy and wider excisions might have contributed to this problem.

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Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects.

Charles Butler, A Gündeslioglu, Miguel Rodriguez-Bigas (2008)

Perineal wound complications after chemoradiotherapy and abdominoperineal resection (APR) for anorectal cancer occur in up to 60% of patients, including perineal abscess and wound dehiscence. Vertical rectus abdominis myocutaneous (VRAM) flaps have been used in an attempt to reduce these complications by obliterating the noncollapsible dead space with vascularized tissue and closing the perineal skin defect with nonirradiated flap skin. Many surgeons are reluctant to use VRAM flaps unless primary closure is not possible. All patients who underwent chemoradiotherapy and APR during a 12-year period at the University of Texas MD Anderson Cancer Center were retrospectively reviewed. Patient, tumor, and treatment characteristics and surgical complications and outcomes were compared between patients who underwent VRAM flap reconstruction of wounds that could have been closed primarily (flap group, n = 35) and those who had primary closure of the perineal wound (control group, n = 76). Overall, there were no significant differences in the incidence of perineal wound complications between the groups; the flap group had a significantly lower incidence of perineal abscess (9% versus 37%, p = 0.002), major perineal wound dehiscence (9% versus 30%, p = 0.014), and drainage procedures required for perineal/pelvic fluid collections (3% versus 25%, p = 0.003) than the control group had. Despite flap harvest and the need for donor site closure in the flap group, there was no significant difference in abdominal wall complications between groups during the study's mean patient followup of 3.8 years. VRAM flap reconstruction of irradiated APR defects reduces major perineal wound complications without increasing early abdominal wall complications. Strong consideration should be given to immediate VRAM flap reconstruction after chemoradiation and APR.

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Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis.

Chris Devulapalli, Anne Jia Wei, Jennifer R DiBiagio … (2016)

Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications.

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Author and article information

Contributors

P. J. Tanis:

ORCID: http://orcid.org/0000-0002-3146-3310

+31 20 566 9111 , P.J.Tanis@amsterdamumc.nl

Journal

Journal ID (nlm-ta): Tech Coloproctol

Journal ID (iso-abbrev): Tech Coloproctol

Title: Techniques in Coloproctology

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1123-6337

ISSN (Electronic): 1128-045X

Publication date (Electronic): 20 August 2019

Publication date PMC-release: 20 August 2019

Publication date (Print): 2019

Volume: 23

Issue: 8

Pages: 751-759

Affiliations

[1 ]ISNI 0000000084992262, GRID grid.7177.6, Department of Surgery, , Amsterdam University Medical Centres, University of Amsterdam, ; Meibergdreef 9, Post Box 22660, 1100 DD Amsterdam, The Netherlands

[2 ]ISNI 0000000084992262, GRID grid.7177.6, LEXOR, Centre for Experimental and Molecular Medicine, Oncode Institute, Cancer Centre Amsterdam, , Amsterdam UMC, University of Amsterdam, ; Meibergdreef 9, Amsterdam, The Netherlands

[3 ]ISNI 000000040459992X, GRID grid.5645.2, Department of Surgical Oncology, , Erasmus Medical Centre, Cancer Institute, ; Doctor Molewaterplein 40, Rotterdam, The Netherlands

[4 ]ISNI 0000 0004 0398 8384, GRID grid.413532.2, Department of Surgery, , Catharina Hospital Eindhoven, ; Michelangelolaan 2, Eindhoven, The Netherlands

[5 ]GRID grid.440159.d, Department of Surgery, , Flevo Hospital, ; Hospitaalweg 1, Almere, The Netherlands

[6 ]ISNI 0000000084992262, GRID grid.7177.6, Department of Plastic and Reconstructive Surgery, , Amsterdam UMC, University of Amsterdam, ; Meibergdreef 9, Amsterdam, The Netherlands

Author information

P. J. Tanis http://orcid.org/0000-0002-3146-3310

Article

Publisher ID: 2055

DOI: 10.1007/s10151-019-02055-1

PMC ID: 6736901

PubMed ID: 31432332

SO-VID: 5d12a693-46cd-42b0-a2ba-f1cdf87cbeed

License:

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.

History

Date received : 28 November 2018

Date accepted : 24 July 2019

Custom metadata

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: rectal neoplasms,abdominoperineal resection,surgical flaps,tissue transfer,gluteal turnover flap,perineal wound healing

Data availability:

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: rectal neoplasms, abdominoperineal resection, surgical flaps, tissue transfer, gluteal turnover flap, perineal wound healing

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer

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Abstract

Background

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Results

Conclusions

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Karger: Gastroenterology

Most cited references 22

Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.

Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects.

Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis.

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