Background Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). Methods A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. Results Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. Conclusion This position statement updates clinicians on current evidence around perineal closure after APE surgery.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/codi.14348

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement.

Aim

Adenocarcinoma of the lower rectum is clinically challenging because of the need to choose between a wide excision to achieve oncological clearance, on the one hand, and sphincter conservation to maintain anal function, on the other. The English National Low Rectal Cancer Development Programme (LOREC) was developed under the auspices of the Association of Coloproctology of Great Britain and Ireland and the English National Cancer Action Team to improve the outcome of low rectal cancer in England.



Method

LOREC was initiated focusing on preoperative imaging, selective neoadjuvant therapy, optimal surgical treatment and detailed pathological assessment of the excised specimen. Its key elements were 1-day multidisciplinary team (MDT) workshops, cadaveric surgical training, surgical mentoring, pathological audit and radiological workshops.



Results

Overall, 147 (89.6%) of 164 MDTs from 151 National Health Service (NHS) Trusts (some with two MDTs) in England participated in 15 workshops in Basingstoke or Leeds. In addition, 112 surgeons attended a 1-day cadaveric training programme in Bristol, Newcastle or Nottingham, with the main focus on extralevator abdominoperineal excision and pelvic reconstruction, with input from anatomists and from colorectal and plastic surgeons.



Conclusion

Optimal staging, selective preoperative chemoradiotherapy and precise surgery were considered as crucial to improve the outcome for patients with low rectal cancer.

The English National Low Rectal Cancer Development Programme: key messages and future perspectives

Background: The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. Methods: A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. Results: The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. Conclusions: Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods.

Summary Background In oncological perineal reconstructions, the internal pudendal artery perforator (IPAP) flap is our flap of choice, supplied by perforator vessels from the internal pudendal artery and innervated by branches from the pudendal nerve and the posterior femoral cutaneous nerve. Data related to the evaluation of its cutaneous sensibility are scarce, discrepant, and subject to methodological criticism. Objective The objective of this study was to evaluate the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction and compare it with the preoperative cutaneous sensibility of the gluteal fold (flap donor area). Methods A prospective study of 25 patients undergoing abdominoperineal excision of rectum (APER) and reconstruction with bilateral VY advancement IPAP flap was conducted. The tactile, pain, thermal, and vibration sensibilities were analyzed in four areas of the gluteal fold preoperatively and in the four corresponding areas of the flap 12 months after surgery. Tactile sensibility was assessed using the Pressure Specified Sensory Device™ (PSSD™), which measures the pressure applied to the skin. The other types of sensibility were analyzed using a needle for pain, hot/cold contact for thermal, and a tuning fork for vibration sensibility. Results A comparison between tactile sensibility thresholds on the gluteal fold preoperatively and on the flap 12 months after surgery showed no statistically significant difference, with p values >0.05 in all four areas evaluated. All patients had preserved pain, thermal, and vibration sensibility in all four areas, postoperatively. Conclusion In oncological perineal reconstructions after APER, it is expected that the cutaneous sensibility on the IPAP flap be maintained.

https://www.jprasurg.com/article/S1748-6815(14)00594-4/pdf

Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions

Aim
The study investigated the effect of collagen mesh-assisted closure at the donor site in preventating the formation of incisional hernia following a vertical rectus abdominis myocutaneus (VRAM) flap as part of pelvic surgery for recurrent colorectal cancer..

Method
The study was a double blinded randomised controlled superiority trial performed designed according to the Consort Statement. Eligible patients undergoing surgery for advanced colorectal pelvic malignancy including a VRAM flap were prospectively randomised to conventional abdominal wound closure or collagen mesh-assisted closure. The primary endpoint was incisional herniation at one year confirmed by computerised tomography (CT). Secondary endpoints were CT-verified incisional herniation at three and 36 months, clinically recognizable incisional herniation, donor site and reconstructive site complications, surgical mortality, postoperative morbidity, postoperative recovery and survival.

Results
58 (29 conventional closure; 29 mesh-assisted closure) patients were included. At one year incisional herniation on the CT scan was found in 12 (50%) of 24 patients in the conventional closure group, and in 8 (33%) of 24 in the mesh-assisted closure group (p=0.38). No significant difference between the groups was found in surgical mortality, early or late complications or survival. Donor site morbidity was comparable between the two groups.

Conclusion
No preventative effect of collagen mesh-assisted closure was observed following VRAM flap reconstruction.

This article is protected by copyright. All rights reserved.

Double-blind randomized controlled trial of collagen mesh for the prevention of abdominal incisional hernia in patients having a vertical rectus abdominis myocutaneus flap during surgery for advanced pelvic malignancy.

Aim

To examine the short-term outcomes of perineal reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap following abdominoperineal excision (APE).



Method

Retrospective case note review of all patients undergoing APE and primary VRAM reconstruction between July 2001 and February 2012 in a district general hospital tertiary referral centre for APE. Complications were categorized using the Clavien–Dindo classification, which grades complications from I to V in order of increasing severity.



Results

Fifty-five consecutive patients (31 men, median age 65, range 38–84 years) underwent APE with VRAM flap reconstruction, 15 for anal cancer and 40 for rectal cancer. Median length of stay was 11 days but was significantly shorter in the laparoscopic group compared with the open group (8 vs 12 days; P < 0.01) and in patients who did not experience any complications (P < 0.05). Four patients (7%) had major complications (Grade 3 and above) directly related to the flap or donor site.



Conclusion

VRAM reconstruction of the perineum can be safely performed following APE with results that compare favourably with other techniques. Most flap complications are minor, although these are still associated with an increase in the length of hospital stay.

Vertical rectus abdominis myocutaneous flap reconstruction of the perineal defect after abdominoperineal excision is associated with low morbidity

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Vertical rectus abdominis myocutaneous flap reconstruction of the perineal defect after abdominoperineal excision is associated with low morbidity