Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma – <scp>ACPGBI</scp> Position Statement

Foster, Jake; Tou, Samson; Curtis, Nathan; Smart, Neil J.; Acheson, Austin G; Maxwell‐Armstrong, C.; Watts, Andrew; Singh, Baljit; Francis, Nader

doi:10.1111/codi.14348

Cited by 55 publications

(33 citation statements)

References 63 publications

(108 reference statements)

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“…Although VRAM flap closure has been effectively used in selective populations, 8 there remains the issue of donor and recipient site morbidity. 43,47 A smaller flap without donor site problems such as the perineal turnover flap 48 seems attractive. We are currently evaluating the effectiveness of a modified gluteal turnover flap 49 for routine use after APR, and we consider larger fascio-cutaneous gluteal or VRAM flaps only for the wider perineal defects with a high risk of sinus formation.…”

Section: Discussionmentioning

confidence: 99%

A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer

Blok

Hagemans²,

Klaver

et al. 2020

Annals of Surgery

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The objective of this systematic review and meta-analysis was to examine the effects of omentoplasty on pelviperineal morbidity following abdominoperineal resection (APR) in patients with cancer. Background: Recent studies have questioned the use of omentoplasty for the prevention of perineal wound complications. Methods: A systematic review of published literature since 2000 on the use of omentoplasty during APR for cancer was undertaken. The authors were requested to share their source patient data. Meta-analyses were conducted using a random-effects model. Results: Fourteen studies comprising 1894 patients (n ¼ 839 omentoplasty) were included. The majority had APR for rectal cancer (87%). Omentoplasty was not significantly associated with the risk of presacral abscess formation in the overall population (RR 1.11; 95% CI 0.79-1.56), nor in planned subgroup analysis (n ¼ 758) of APR with primary perineal closure for nonlocally advanced rectal cancer (RR 1.06; 95% CI 0.68-1.64). No overall differences were found for complicated perineal wound healing within 30 days (RR 1.30; 95% CI 0.92-1.82), chronic perineal sinus (RR 1.08; 95% CI 0.53-2.20), and pelviperineal complication necessitating reoperation (RR 1.06; 95% CI 0.80-1.42) as well. An increased risk of developing a perineal hernia was found for patients submitted to omentoplasty (RR 1.85; 95% CI 1.26-2.72). Complications related to the omentoplasty were reported in 4.6% (95% CI 2.5%-8.6%). Conclusions: This meta-analysis revealed no beneficial effect of omentoplasty on presacral abscess formation and perineal wound healing after APR, while it increases the likelihood of developing a perineal hernia. These findings do not support the routine use of omentoplasty in APR for cancer.

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Section: Discussionmentioning

confidence: 99%

A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer

Blok

Hagemans²,

Klaver

et al. 2020

Annals of Surgery

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“…Previous studies and meta-analyses have reported major morbidity rates between 10-30% and perineal wound healing problems from 11 up to 50% [21][22][23][24][25][26]. Especially in irradiated patients, perineal wound healing is problematic and sometimes requires primary or secondary reconstruction with musculocutaneous flaps to achieve perineal closure [26][27][28][29][30].…”

Section: Introductionmentioning

confidence: 99%

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

et al. 2020

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Background Abdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE) Methods This multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien-Dindo ≥ 3), histopathology results, and perineal wound healing. Results A total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention. Conclusions TpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.

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“…The use of neoadjuvant chemoradiotherapy and more aggressive approaches to achieve an R0 resection of anorectal cancers including pelvic/perineal exenterative surgery often necessitate the use of a flap reconstruction technique to close the wound. The Association of Coloproctology of Great Britain and Ireland position statement on closure of perineal wounds states that myocutaneous flaps can be considered for difficult wounds but does not identify a preferred method (weak recommendation) .…”

Section: Introductionmentioning

confidence: 99%

Single centre experience of bilateral gracilis flap perineal reconstruction following extra‐levator abdominoperineal excision

et al. 2019

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Aim A variety of tissue flaps have been described for the closure of perineal wounds following abdominoperineal excision of the rectum (APE) or exenteration for locally advanced/recurrent rectal cancer and salvage surgery for anal cancer. The aim of this study was to demonstrate the utility of the bilateral pedicled gracilis muscle flaps (BPGMFs) as a reconstruction option in these patients. This is of particular benefit when using a laparoscopic approach for the abdominal component of the operation, avoiding disruption of the abdominal wall and risk of herniation with other reconstruction options, e.g. vertical rectus abdominis myocutaneous flaps. Method This is a retrospective single centre case series of patients who underwent reconstruction of perineal defects using BPGMFs using a novel weave technique, from January 2008 to August 2017. Results There were 25 patients (16 female), with a median follow‐up of 19 months (3–102). The indications for BPGMFs were cancer resection (21) and perineal hernia (4). The median length of stay was 14 days (6–60). All‐cause mortality was 36% within the follow‐up period. A healed perineal wound was achieved in 72% of patients within 30 days (84% of patients received neoadjuvant chemoradiotherapy). The overall donor site complication rate was 20% (including infection, dehiscence, numbness, haematoma and seroma) and 28% for the perineal site (including infection, dehiscence and prolapse). Conclusions BPGMFs provide an important option for reconstruction of the perineum particularly with a minimally invasive approach or with two stomas.

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

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

Cited by 55 publications

References 63 publications

A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer

A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

Single centre experience of bilateral gracilis flap perineal reconstruction following extra‐levator abdominoperineal excision

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