Perineal Wound Complications after Abdominoperineal Resection

Abstract

Perineal wound complications following abdominoperineal resection (APR) is a common occurrence. Risk factors such as operative technique, preoperative radiation therapy, and indication for surgery (i.e., rectal cancer, anal cancer, or inflammatory bowel disease [IBD]) are strong predictors of these complications. Patient risk factors include diabetes, obesity, and smoking. Intraoperative perineal wound management has evolved from open wound packing to primary closure with closed suctioned transabdominal pelvic drains. Wide excision is used to gain local control in cancer patients, and coupled with the increased use of pelvic radiation therapy, we have experienced increased challenges with primary closure of the perineal wound. Tissue transfer techniques such as omental pedicle flaps, and vertical rectus abdominis and gracilis muscle or myocutaneous flaps are being used to reconstruct large perineal defects and decrease the incidence of perineal wound complications. Wound failure is frequently managed by wet to dry dressing changes, but can result in prolonged hospital stay, hospital readmission, home nursing wound care needs, and the expenditure of significant medical costs. Adjuvant therapies to conservative wound care have been suggested, but evidence is still lacking. The use of the vacuumassisted closure device has shown promise in chronic soft tissue wounds; however, experience is lacking, and is likely due to the difficulty in application techniques.

Real world dehiscence rates for patients undergoing abdominoperineal resection with or without myocutaneous flap closure in the national surgical quality improvement project

“…This contradicts some prior studies though these may have been limited in generalizability due to small sample size and/or salvage indication [1,10,[22][23][24][25]. While a pathophysiologic mechanism for increased wound complications following neoadjuvant therapy certainly exists [26], the evidence for increased wound complications following neoadjuvant radiation has been conflicting.…”

“…Perineal wound complications present a major challenge, occurring in 14 to 80 % of patients in some series [1]. Particularly for patients undergoing neoadjuvant radiotherapy, multiple surgical techniques have been proposed to address this difficult problem including flaps of omentum, gracilis, gluteus, and vertical rectus abdominus (VRAM) muscle and biologic mesh [1][2][3]. Despite multiple retrospective, single-center studies, the real-world rate of perineal wound complications following APR outside of oncologic centers of excellence has not been defined.…”

Surgery Is an Effective Option after Failure of Chemoradiation in Cancers of the Anal Canal and Anal Margin

“…The majority of postoperative morbidity was related to perineal dehiscence of irradiated tissues, and several surgical techniques are now available in order to prevent perineal dehiscence. First, wide suture of the perineum associated with vacuumassisted closure appears to be an effective technique, but this requires a relatively long period of time for the patient to completely heal [20,21] , which is partially due to the surgical procedure itself. However, even if all the patients in this series had had omental pedicle flaps, this may not have been sufficient for satisfactory healing after radiation.…”

Incisional Negative-Pressure Wound Therapy for Perineal Wounds After Abdominoperineal Resection for Rectal Cancer, a Pilot Study

“…While previously conducted studies have shown a beneficial effect for conventional NPWT in case of wound complications, it is known that NPWT on perineal incisions can be painful, discourage postoperative mobilization, and especially in woman, it may be difficult to maintain an airtight seal. 1 The new iNPWT device, PICO, is light, portable, and canister-free, and therefore has the potential to be very patient friendly. The use of PICO on laparotomy incisions in patients with Crohn's disease undergoing abdominal surgery was previously studied in Italy, where the authors report a decrease in wound infections as well as hospital stay in patients treated with PICO.…”

“…1 This may be caused by the large cavity in the pelvis that exists after resection, where blood and fluid can accumulate and accelerated bacterial growth can occur subsequently. Furthermore, neoadjuvant treatment for rectal cancer is a known risk factor for perineal wound complications.…”