Propensity Score Adjusted Comparison of Pelviperineal Morbidity With and Without Omentoplasty Following Abdominoperineal Resection for Primary Rectal Cancer

Abstract

BACKGROUND: Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear. OBJECTIVE: This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer. DESIGN: This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding. SETTING: The study was undertaken in 2 teaching hospitals and 1 university hospital. PATIENTS: Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included. MAIN OUTCOME MEASURES: The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period. RESULTS: Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45–1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46–3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation. LIMITATIONS: This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts. CONCLUSION: In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918.

CT assessment of the quality of omentoplasty and its implications for perineal wound healing

“…The higher perineal hernia rate after OP is in line with previous studies [7,8]. Although a causal relation cannot be confirmed, the hypothesis is that the pedicled omentum will function as a large amount of loose fatty tissue that will easily descend through the pelvic outlet in the absence of a pelvic floor, while a few loops of small bowel are restricted by a certain mesenteric length in the possibility of herniating at the level of the perineum.…”

“…It could therefore be that a true effect may not be demonstrated due to relatively low numbers. However, as only few patients would require surgical management, and this study as well as two recent large studies showed no significant reduction in reoperation rate for ileus [7,8], it is questionable whether this potential effect of OP would be clinically relevant.…”

“…If the OP appears to be of poor quality on postoperative imaging-due to for example partial necrosis-the outcomes appear to be even worse than not performing an OP. Furthermore, the protective effect in preventing small bowel obstruction remains speculative, and there is likely an elevated risk of developing a perineal hernia after OP if considering recent literature [7][8][9].…”

“…Omentoplasty (OP) has been advocated to reduce the frequency of perineal wound problems and prevent the small bowel from entering into the narrow pelvis with a risk of getting trapped [6]. However, application of OP is currently highly debated as there is increasing evidence to suggest that OP does not affect the occurrence of pelviperineal wound complications after APR for rectal cancer [7,8]. Moreover, there seems a similar need for operative management of small Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00384-019-03412-0) contains supplementary material, which is available to authorized users.…”

Selection and Outcomes in Abdominoperineal Resection

“…Blok et al in a retrospective study of 106 patients who underwent an omentoplasty, demonstrated that omentoplasty did not lower the incidence or duration of perineal morbidity in patients undergoing abdominoperineal resection for rectal cancer. Additionally, they found that the omentoplasty itself was associated with a risk for reoperation (37).…”