Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

Abstract

Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusion. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications

“…Findings for MCF reconstruction were similar, although rates of perineal wound morbidity and reoperation were high. These findings are consistent with those of a systematic review by Buscail et al [36]. They concluded that although patients who underwent MCF reconstruction following APR had reduced total and major wound complications (compared with primary closure), in patients who underwent MCF reconstruction post-PE, there were increased major and total perineal wound complications.…”

Comparison of Perineal Closure Techniques after Abdominoperineal Resections for Carcinoma of the Anus

“…13 Contrary to this, recent systematic reviews, meta-analysis and a randomized control trial have found myocutaneous flaps to lower perineal wound morbidity. 4,12,29 Nonetheless, previous NSQIP studies have combined anal and rectal cancer into a single cohort potentially skewing the results. 13,15 Utilizing solely anal cancer is crucial as morbidity and wound complication rates are known to differ between rectal and anal cancer APR’s.…”

“…2 The nature of the resection from APR's often inherently results in substantial perineal defects that become a challenge to close in a tension free fashion, and complications of wound healing as a result of this occur frequently. 4 In addition, neoadjuvant radiotherapy increases the risk of impaired wound healing and contributes to the significant morbidity associated with APR. 5 Historically, wound complications were reported to occur at 40-45%, but in recent years, these rates can be as high as 60-70%.…”

Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis

“…Multiple surgical options for closure of perineal defects have been described: primary closure, use of acellular dermal matrix, loco-regional flaps, and pedicled muscular flaps. Two studies demonstrated the superiority of muscular flaps compared to primary closure [ 1 , 17 ]. VRAM and gracilis are two popular muscle flaps used in perineal reconstruction, motivating their comparison in this meta-analysis.…”

“…Flaps have been shown to resist bacterial infection in vivo and favor wound healing by providing a steady blood supply that delivers oxygen, immunological cells, and antibiotics to the defect site [ 10 , 15 , 16 ]. A wide variety of techniques exist to reconstruct perineal defects following oncologic resection, but muscular pedicled flaps have gained interest among professionals due to their robust blood supply, the absence of microsurgical anastomosis, and their ability to offer tension-free closure [ 1 , 17 , 18 ]. Among them, VRAM and gracilis are two popular options [ 1 , 19 , 20 , 21 ].…”