Background:Reconstruction following abdominoperineal resection or pelvic exenteration is commonly performed with regional flaps from the thigh or abdomen This study compared the surgical outcomes and complications in cancer patients who underwent immediate reconstruction of these defects with verti

Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects.

Background:Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to co

Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis

Objective Perineal wound complications after abdominoperineal excision (APE) for anorectal cancer represent a considerable source of morbidity for patients. Strategies to improve wound healing include reconstruction with myocutaneous flaps. This is an evidence-based review of reconstruction of pelvic defects after APE, using rectus abdominus (RAM), gracilis and gluteus maximus flaps.

Method  A Pubmed search was performed using MESH headings.

Results  Thirty-six studies reported outcomes of interest. Five controlled studies reported improved outcomes after APE and chemoradiotherapy with RAM reconstruction and two controlled studies reported improved outcomes with gracilis reconstruction. There were seven patients with total flap loss after RAM reconstruction, in a combined 300 patients. There were eight patients with complete cutaneous necrosis after gracilis reconstruction in a combined 83 patients.

Conclusion  Data from the controlled studies support the use of myocutaneous flaps for single-stage reconstruction after APE in the presence of chemoradiotherapy. Ultimately, the choice of flap depends on the goals of reconstruction, size of the defect and the availability of donor tissue. The implications of an expanding role for radiotherapy in the treatment of low rectal cancer and radical dissection to achieve negative circumferential margins, necessitate close co-operation between colorectal and reconstructive surgeons to achieve APE with reduced wound morbidity.

Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision.

For many patients with bulky, locally advancedprimary or recurrent pelvic malignancy, aggressivesurgical extirpation is the best treatment option. Toremove large pelvic tumors that invade adjacent or-gans without compromising curability, an en-blocexcision of the tumor and adjacent organs is oftenrequired. Total pelvic exenteration—the removal ofall pelvic organs, including the rectum, bladder, andreproductive organs—has traditionally been associ-atedwithahigh rateofcomplicationsandfewlong-term survivors.

Pelvic exenteration for advanced pelvic malignancies.

Historically, morbidity and mortality rates related to surgery for locally recurrent rectal cancer (LRRC) have been >70% and 30%, respectively [1, 2, 3]. Because of the excessive operative risks, the benefit of such resections has been questioned and — although radical operation for LRRC was conceptualized and reported more than 60 years ago — for years it has not been accepted as being standard procedure. More appropriate selection of candidates for resection due to advances in imaging modalities, improvement in surgical techniques, establishment of specialized multidisciplinary surgical teams, and improvement in quality of perioperative management have resulted in better outcomes in recent years. Currently, mortality rates vary between 0–5% at 1 month and 8% at 3 months [4]. The causes of death are mainly disseminated coagulopathies related to prolonged sepsis and blood loss, multiorgan failure, cardiac events, and pulmonary embolism [5, 6]. Morbidity remains significant, ranging from 15 to 68%, and increases with the complexity of resection [7, 8, 9, 10]. Bleeding is the main and most severe intraoperative complication, and occurs in 0.2–9% of cases, and related mortality is high (4%) [11, 12, 13, 14]. The principal postoperative complications include pelvic abscess (7–50%), intestinal obstruction (5–10%), enterocutaneous or enteroperineal fistulas (1.2%), perineal wound dehiscence (4–24%), and cardiovascular, renal, and pulmonary complications (1–20%) [5, 7, 8].

Mortality and Morbidity

Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery.

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Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery.