Perineal Healing and Survival After Anal Cancer Salvage Surgery: 10-Year Experience with Primary Perineal Reconstruction Using the Vertical Rectus Abdominis Myocutaneous (VRAM) Flap

Abstract

Salvage surgery of recurrent or persistent anal cancer following radiotherapy is often followed by perineal wound complications. We examined survival and perineal wound complications in anal cancer salvage surgery during a 10-year period with primary perineal reconstruction predominantly performed using vertical rectus abdominis myocutaneous (VRAM) flap. Between 1997 and 2006, 49 patients underwent anal cancer salvage surgery. Of these, 48 had primary reconstruction with VRAM. Overall survival was computed by the Kaplan-Meier method and mortality rate ratios (MRRs) by Cox regression. One patient (2%) died within 30 days postoperatively. Postoperative complications necessitated reoperation in eight (16%) patients. We found no major perineal wound infections. Major perineal wound breakdown occurred in the only patient in whom VRAM was not used. Five-year survival was 61% [95% confidence interval (CI) 43-75%]. Free resection margins (R0) were obtained in 78% of patients, with 5-year survival of 75% (95% CI 53-87%). Involved margins, microscopically only (R1) or macroscopically (R2), strongly predicted an adverse outcome [age-adjusted 2-year MRRs (95% CI) R1 vs. R0 = 4.1 (0.7-23.6), R2 vs. R0 = 10.9 (2.2-54.2)]. We conclude that anal cancer salvage surgery can yield long-time survival but obtaining free margins is critical. A low rate of perineal complications is achievable by primary perineal reconstruction using VRAM flap.

Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience

“…This is similar to the reported rate of 2% by Sunesen 12 and the <5% flap necrosis reported previously in the literature. 14 We believe that if the origin is divided, then the flap does need a suture to support it to the bladder or pelvic side wall to minimise traction on the pedicle.…”

“…Others have reported rates of between 0% and 11%. 12,[16][17][18] In our series we had a 19% incisional hernia rate, which is comparable with the literature. As all of these (3) occurred in our first eight patients, we have adopted the practice of reinforcing the donor site with mesh if it appears to be at risk of an incisional hernia due to patient size, build or being under tension at closure.…”

“…A series of 49 patients who had primary reconstruction with a RAM flap has been published, 9,12 with major wound breakdown occurring in only one patient. In the most recent paper published, this figure was 17% for all types of myocutaneous flaps.…”

Results of Surgical Salvage Treatment for Anal Canal Cancer: A Retrospective Analysis with Overview of the Literature

“…So a single-stage primary reconstructive procedure is feasible, with an acceptable complication rate and high level of patient satisfaction [35] . These data were confirmed by Sunesen et al [36] who reported that salvage surgery can yield long-time survival in almost two-thirds of patients failing primary RT or CRT with low rate of major perineal complications, when primary perineal reconstruction with VRAM flap is performed. They recommended the routine use of primary perineal reconstruction with a VRAM flap in anal cancer salvage surgery.…”

Primary Abdominal Wall Reinforcement With Synthetic Mesh Following Harvesting Of Vertical Rectus Abdominis Myocutaneous Flaps In Multivisceral Pelvic Resections

“…Fisher's exact probability test Fisher's exact probability test (3,10,11,12). As shown in earlier investigations (9,13,14), a VRAM flap introduces wellvascularized tissue that fills the pelvic defect, providing structural support for internal organs and interposing healthy skin in the perineal wound. Maricevich et al (15) demonstrated that VRAM flaps represent a reliable option for reconstruction of the large-volume defects that arise after sacrectomies.…”