Objectives: Upon completion of this article in the setting of Crohn disease, the reader should be able (1) to describe factors that increase the risk for postoperative perineal wound complications, (2) to discuss preoperative strategies aimed at minimizing the risk for postoperative perineal wound complications, and (3) to evaluate and manage postoperative perineal wound complications.The treatment of complex perineal wounds starts with a good understanding of the etiology. Any perineal wound can harbor sepsis, subsequently dehisce, and become a chronic, long-term problem. Certain diseases and procedures are far more likely to result in wound infection and/or delayed wound healing, and a specific knowledge of this is important and necessary. Increased risk for perineal wound breakdown is typically due to either high-risk procedures that are associated with an increased risk of breakdown or patient comorbidities that potentiate these risks. Conditions involving high-risk perineal wounds include total proctectomy for Crohn disease (CD), total proctectomy for recurrent or residual anal cancer, and abdominoperineal resection after neoadjuvant chemoradiation for advanced distal rectal cancer. Risk of surgical site infection and nonhealing following these procedures is high, and patient comorbidities such as diabetes, obesity, and malnutrition seem to worsen outcomes. In this chapter, we will serve to discuss common causes of perineal wound complications as well as specific strategies for treatment and prevention. [1][2][3][4][5] Total proctectomy is performed appropriately for a variety of conditions, including severe, refractory anorectal CD unresponsive to medical management, as well as radiated anal and distal rectal cancers. Although the basic procedure (proctectomy with excision of surrounding anal margin dermis and epidermis) is common to all of these conditions, there are special considerations and circumstances that distinguish each of these. The Perineal WoundThe perineal wound resulting from an abdominoperineal resection (APR) has always been considered troublesome. Miles' original description of the treatment of the perineal incision involved leaving it open to heal by secondary intention, a strategy resulting in a long-term chronic wound. 6 Modern use of chemotherapy and postoperative radiation called for more reliable closure of the perineum to expedite post operative care. However, even when primary closure is instituted, high rates of both wound infection (11-16%) and delayed wound healing can be apparent. 2-6 A recent study from the University of Pennsylvania examined the effect of surgical technique on perineal wound infection rates. In this study, 150 patients undergoing APR for both inflammatory Keywords ► proctectomy ► Crohn perineum ► perineal wound ► surgical site infection AbstractComplex perineal wounds are at risk for nonhealing. High-risk procedures include proctectomy for Crohn disease, anal cancer and radiated distal rectal cancers. A basic understanding of both patient and procedural risk...
Previous studies have demonstrated that the division of sphincter muscle in the treatment of anal fistula may precipitate fecal incontinence. Cutting setons may pose a particular risk of unrecoverable injury to the sphincter apparatus. To evaluate if the use of an adjustable cutting seton mitigates this risk, we performed a retrospective review of all patients operated on for anal fistulae in a 10-year period by a single surgeon. Adjustable cutting setons (consisting of heavy silk ligature with patient-controllable tension) were used selectively. Forty-seven patients met the study criteria. Ninety-four per cent of the fistulae treated were transsphincteric. All of the fistulae were treated with at least partial fistulotomy. Ninety-nine per cent of patients were followed to completion of treatment. One (2%) patient subsequently developed fecal incontinence, and four (9%) developed a recurrent or persistent fistula in the same location. Adjustable cutting setons have been used in our practice with a high success rate and low risk of complications. Our data support adjustable cutting setons as a useful tool in the surgeon's repertoire for treating fistulae that involve the anal sphincter complex.
Nearly all reoperation patients (11/12, 92%) had compromised urethras, defined by prior implant or urethral surgery (7/12, 58%) or radiation (4/ 12, 33%).CONCLUSIONS: Synchronous ipsilateral high submuscular placement of urologic prosthetic balloons and reservoirs can be done without an increase in infectious/erosive complications or device failure.
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