Perineal Hernia Repair After Abdominoperineal Rectal Excision

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.

Although uncommon, locally recurrent rectal cancer (LRRC) and locally recurrent anal cancer (LRAC) after definitive chemoradiation can confer high morbidity and mortality. Although surgery is critical for management, recent studies show promising results with other locally directed and/or systemic treatment approaches. Here we review the literature to examine recent advances in management of this patient population. For LRRC, studies demonstrate success with newer surgical approaches and redefine contraindications for surgery. The roles of brachytherapy, repeat external beam irradiation, and induction chemotherapy are under investigation. Advances in LRAC show that surgery remains a core element of treatment after primary chemoradiation failure. Recent reports of overall survival are promising. Surgery remains the mainstay of treatment for LRRC and LRAC, and overall survival is improving. Benefits of newer surgical, radiotherapeutic, and other treatment approaches are being elucidated. These findings pave the way for further improvements in cancer-specific outcomes and quality of life.

Local Therapy Options for Recurrent Rectal and Anal Cancer: Current Strategies and New Directions

Introduction: Treatment for Anal cancer is carried out in regional cancer centres but when chemoradiation fails or is ineffective then there is a role for salvage surgery but carries considerable morbidity and mortality. We reviewed clinicopathological outcomes for patients undergoing surgery following Chemoradiotherapy (CRT) for anal cancer. Materials and methods: A retrospective review of patient data from patients undergoing surgery for anal cancer from 2008 -2018 was performed. Patients were identifi ed from the anal cancer MDT records and the departmental surgical logbook. Results: Forty patients were identifi ed (72.5% female) with a median [IQR] age of 62 [18.25] years. Thirty-three patients underwent APER and seven underwent pelvic exenteration, with 25 (62.5%) having fl ap reconstruction of the perineum. Post-operative complications were identifi ed in 25 (62.5%) patients, 18 (72%) of which were Clavien-Dindo I-II and 7 (18%) were III-IV. There was one 90-day mortality. The overall 1, 3, and 5-year survival was 76.4%, 47.8% and 35.2% respectively. Conclusion: Chemoradiotherapy remains the gold standard for the treatment of anal cancer, with salvage surgery preserved for cases of residual or recurrent disease, or for palliation. We report a median time from completion of CRT to surgery of 12 months, an R0 resection rate of 70%, and 5-year survival of 35.2%. The reason for low 5-year survival requires analysis. Robust prospective data collection is needed to fully quantify outcomes in this important group.

/pdf/outcomes-of-surgery-following-chemoradiotherapy-for-anal-oylindehz2.pdf

Outcomes of surgery following chemoradiotherapy for anal cancer: A 10-year retrospective study

Les formes metastatiques ou avancees des cancers du canal anal sont rares. En cas de recidive locoregionale, la chirurgie de rattrapage offre, au prix d’une colostomie terminale definitive, une chance de remission prolongee pour les patients avec une morbidite acceptable. Le facteur pronostique principal est la qualite de l’exerese chirurgicale complete R0, amenant a envisager des exereses elargies avec reconstruction perineale par lambeau myofasciocutane. Dans les formes avancees non operables ou metastatiques, de recents progres ont permis de mieux definir les standards therapeutiques. Les protocoles DCF modifie et paclitaxel‒ carboplatine sont desormais les deux schemas de premiere ligne de reference. L’immunotherapie par anti-PD-1 a montre des resultats encourageants chez certains patients. La place de la chirurgie chez les patients oligometastatiques reste a definir et se discute au cas par cas en RCP.

Traitement des formes métastatiques et avancées des carcinomes épidermoïdes du canal anal

AIM Chemoradiotherapy remains the first line of treatment for anal cancer with surgery reserved for cancer recurrence or persistence. The low incidence of anal cancer means that the numbers undergoing surgery is small with centralization for excision to regional cancer centres. We present our experience of abdominal perineal excision, with reconstruction of the perineal defect (APERR), within a tertiary centre. METHOD Over a 15-year period, data were collected retrospectively from notes of patients who underwent an APERR. The aim was to look at disease-free and overall survival and complications associated with flap reconstruction. RESULTS In the study period, 29 patients [median age = 62 (range: 42-81; interquartile range: 54-68) years] underwent APERR. Median follow-up was 77 (4-200) months. Thirteen patients died during follow-up; eight from their disease, with a median survival time of 16 (4-63) months. Five-year survival was 67%. Nine (31%) patients had recurrence during the follow up period; this was local (n = 2), regional (n = 4), distant (n = 2) or a combination (n = 1). Sixteen (55%) patients developed 24 complications, including nine (31%) flap complications and 10 (34%) parastomal hernias. Flap complications were flap failure (n = 1) requiring direct closure, flap dehiscence (n = 2), necrosis of flap tip (n = 1), wound infection (n = 4) and a bulky flap (n = 1) requiring liposuction. CONCLUSION APERR of anal cancer is a feasible technique with excellent oncological treatment and acceptable long-term complications, although a higher than expected rate of parastomal hernia was noted.

Outcome of surgery for recurrent anal cancer: results from a tertiary referral centre.

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Outcome of surgery for recurrent anal cancer: results from a tertiary referral centre.