Snapshot Study on the Value of Omentoplasty in Abdominoperineal Resection with Primary Perineal Closure for Rectal Cancer

Abstract

BackgroundPerineal wound complications are often encountered following abdominoperineal resection (APR). Filling of the pelvic space by omentoplasty (OP) might prevent these complications, but there is scant evidence to support its routine application.ObjectiveThe aim of this study was to evaluate the impact of OP on perineal wound complications.MethodsAll patients undergoing APR with primary perineal closure (PPC) for non-locally advanced rectal cancer in 71 Dutch centers in 2011 were selected from a cross-sectional snapshot study. Outcomes were compared between PPC with or without OP, which was based on variability in practice among surgeons.ResultsOf 639 patients who underwent APR for rectal cancer, 477 had a non-locally advanced tumor and PPC was performed. Of those, 172 (36%) underwent OP. Patients with OP statistically more often underwent an extralevator approach (32% vs. 14%). Median follow-up was 41 months (interquartile range 22–47). There were no significant differences with or without OP in terms of non-healing of the perineal wound at 30 days (47% vs. 48%), non-healing at the end of follow-up (9% vs. 5%), pelvic abscess (12% vs. 13%) or re-intervention for ileus (5% vs. 3%). Perineal hernia developed significantly more often after OP (13% vs. 7%), also by multivariable analysis (odds ratio 2.61, 95% confidence interval 1.271–5.364; p = 0.009).ConclusionsIn contrast to previous assumptions, OP after APR with PPC appeared not to improve perineal wound healing and seemed to increase the occurrence of perineal hernia. These findings question the routine use of OP for primary filling of the pelvic space.Electronic supplementary materialThe online version of this article (10.1245/s10434-017-6273-9) contains supplementary material, which is available to authorized users.

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.…”

Low Hartmann’s procedure or intersphincteric abdominoperineal resection in the primary treatment of low rectal cancer; a survey among surgeons evaluating current practice

“…This was confirmed in a recent review showing a reduction of perineal wound morbidity after APR when an omentoplasty is created [17]. A large cross-sectional study in the Netherlands, however, revealed no reduction of pelvic abscesses after APR with primary closure of the perineal wound and omentoplasty compared to primary closure without omentoplasty [18]. The present survey found that only 19% of respondents never perform an omentoplasty in iAPR, despite conclusive evidence on the additional value and the need for additional dissection and increase in operating time.…”