Abstract
Purpose
Most patients with anal cancer receive chemoradiotherapy as first-line treatment. Persistent/recurrent tumours will subsequently require an abdomino-perineal resection (APR). A proportion of the 20,000 new cases of rectal carcinoma diagnosed in the UK each year receive neo-adjuvant chemoradiation and then an APR. Healing of the irradiated perineal bed is compromised, resulting in high morbidity. Reconstruction of the perineam with well-vasularised tissue is thought to enhance healing. This study investigates a series of 18 patients who underwent APR for anorectal cancer with flap reconstruction of their perineum.
Materials and methods
A retrospective analysis of all anorectal cancers requiring an APR and flap reconstruction was performed. Casenotes were reviewed and documentation made of risk factors putting them at increased risk of wound complications. Length of stay, morbidity and outcome variables including primary flap healing were recorded.
Results
Between November 2000 and October 2007, 18 cases were performed (M/F = 7:11), six for anal cancer and 12 for low rectal tumours. Pre-operative treatment was chemoradiotherapy in 14 (78%), radiotherapy alone in two (11%) and none in two (11%). Perineal reconstruction consisted of 14 vertical rectus abdominis myocutaneous flaps, three free latissimus dorsi flap and one transverse rectus abdominis myocutaneous flap. Mean hospital stay was 21.8 days (10–54 days). Complete healing was noted in 16 cases with the remaining two continuing to improve under current follow-up. There were no flap losses.
Conclusions
Despite most patients being treated with pre-operative radiotherapy, we have had significant success in obtaining primary healing of the perineal defect after APR.
Similar content being viewed by others
References
Whiteford MH, Stevens KR Jr., Oh S, Deveney KE (2001) The evolving treatment of anal cancer: how are we doing? Arch Surg 136(8):886–891
Ryan DP, Compton CC, Mayer RJ (2000) Carcinoma of the anal canal. N Engl J Med 342(11):792–800
Esiashvili N, Landry J, Matthews RH (2002) Carcinoma of the anus: strategies in management. Oncologist 7(3):188–199
Heidelberger C, Griesbach L, Montag BJ, Mooren D, Cruz O, Schnitzer RJ et al (1958) Studies on fluorinated pyrimidines. II. Effects on transplanted tumors. Cancer Res 18(3):305–317
Bagshaw MA (1961) Possible role of potentiators in radiation therapy. Am J Roentgenol Radium Ther Nucl Med 85:822–833
Vietti T, Eggerding F, Valeriote F (1971) Combined effect of x radiation and 5-fluorouracil on survival of transplanted leukemic cells. J Natl Cancer Inst 147(4):865–870
Nigro ND, Vaitkevicius VK, Considine B Jr (1974) Combined therapy for cancer of the anal canal: a preliminary report. Dis Colon Rectum 17(3):354–356
Epidermoid anal cancer: results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. UKCCCR Anal Cancer Trial Working Party. UK Co-ordinating Committee on Cancer Research. Lancet 348(9034):1049–1054
Nilsson PJ, Svensson C, Goldman S, Glimelius B (2002) Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 89(11):1425–1429
Ferenschild FT, Vermaas M, Hofer SO, Verhoef C, Eggermont AM, de Wilt JH (2005) Salvage abdominoperineal resection and perineal wound healing in local recurrent or persistent anal cancer. World J Surg 29(11):1452–1457
Klebanoff SJ (1980) Oxygen metabolism and the toxic properties of phagocytes. Ann Intern Med 93(3):480–489
Rudolph R, Vande Berg J, Schneider JA, Fisher JC, Poolman WL (1988) Slowed growth of cultured fibroblasts from human radiation wounds. Plast Reconstr Surg 82(4):669–677
Krueger WW, Goepfert H, Romsdahl M, Herson J, Withers RH, Jesse RH (1978) Fibroblast implantation enhances wound healing as indicated by breaking strength determinations. Otolaryngology 86(5):ORL–804–811
Bernatchez SF, Parks PJ, Grussing DM, Matalas SL, Nelson GS (1998) Histological characterization of a delayed wound healing model in pig. Wound Repair Regen 6(3):223–233
Miles WE (1908) A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2:1812–1813
Miles WE (1914) Technique of the radical operation for cancer of the rectum. Br J Surg 2(6):292–305
John H, Buchmann P (1991) Improved perineal wound healing with the omental pedicle graft after rectal excision. Int J Colorectal Dis 6(4):193–196
Manjoney DL, Koplewitz MJ, Abrams JS (1983) Factors influencing perineal wound healing after proctectomy. Am J Surg 145(1):183–189
Alpsan K, Singh A, Ahmad A (1980) Clinical comparison of perineal wound management. Dis Colon Rectum 23(8):564–566
Altemeier WA, Culbertson WR, Alexander JW, Sutorius D, Bossert J (1974) Primary closure and healing of the perineal wound in abdominoperineal resection of the rectum for carcinoma. Am J Surg 127(2):215–219
Kim HK, Jessup JM, Beard CJ, Bornstein B, Cady B, Stone MD et al (1997) Locally advanced rectal carcinoma: pelvic control and morbidity following preoperative radiation therapy, resection, and intraoperative radiation therapy. Int J Radiat Oncol Biol Phys 38(4):777–783
Radice E, Nelson H, Mercill S, Farouk R, Petty P, Gunderson L (1999) Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies. Br J Surg 86(3):349–354
Bullard KM, Trudel JL, Baxter NN, Rothenberger DA (2005) Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 48(3):438–443
Holm T, Lyung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238
Anthony JP, Mathes SJ (1990) The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closure. Arch Surg 125(10):1371–1376 (discussion 1376–1377)
Bartholdson L, Hulten L (1975) Repair of persistent perineal sinuses by means of a pedicle flap of musculus gracilis. Case report. Scand J Plast Reconstr Surg 9(1):74–76
Pezim ME, Wolff BG, Woods JE, Beart RW Jr, Ilstrup DM (1987) Closure of postproctectomy perineal sinus with gracilis muscle flaps. Can J Surg 30(3):212–214
Baek SM, Greenstein A, McElhinney AJ, Aufses AH Jr (1981) The gracilis myocutaneous flap for persistent perineal sinus after proctocolectomy. Surg Gynecol Obstet 153(5):713–716
Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, Steele G Jr et al (1999) Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 6(1):33–37
Yii NW, Niranjan NS (1996) Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 49(8):547–554
Hashimoto I, Nakanishi H, Nagae H, Harada H, Sedo H (2001) The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume. Plast Reconstr Surg 108(7):1998–2005
Luo S, Raffoul W, Piaget F, Egloff DV (2000) Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg 105(1):171–173
Shukla HS, Hughes LE (1984) The rectus abdominis flap for perineal wounds. Ann R Coll Surg Engl 66(5):337–339
Tobin GR, Day TG (1988) Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 81(1):62–73
Skene AI, Gault DT, Woodhouse CR, Breach NM, Thomas JM (1990) Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap. Br J Surg 776:635–637
Erdmann MW, Waterhouse N (1995) The transpelvic rectus abdominis flap: its use in the reconstruction of extensive perineal defects. Ann R Coll Surg Engl 77(3):229–232
Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H (2003) Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br J Surg 90(5):575–580
Buchel EW, Finical S, Johnson C (2004) Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg 52(1):22–26
Kapoor V, Cole J, Isik FF, Sinanan M, Flum D (2005) Does the use of a flap during abdominoperineal resection decrease pelvic wound morbidity? Am Surg 71(2):117–122
Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E (2005) Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 92(4):482–486
Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J et al (2005) Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 12(2):104–110
Gurlek A, Miller MJ, Amin AA, Evans GR, Reece GP, Baldwin BJ et al (1998) Reconstruction of complex radiation-induced injuries using free-tissue transfer. J Reconstr Microsurg 14(5):337–340
Kroll SS, Robb GL, Reece GP, Miller MJ, Evans GR, Baldwin BJ et al (1998) Does prior irradiation increase the risk of total or partial free-flap loss? J Reconstr Microsurg 14(4):263–268
Conflicts of interest statement
None
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Petrie, N., Branagan, G., McGuiness, C. et al. Reconstruction of the perineum following anorectal cancer excision. Int J Colorectal Dis 24, 97–104 (2009). https://doi.org/10.1007/s00384-008-0557-2
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-008-0557-2