Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis.

The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I2 = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.

Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study.

PURPOSE: Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment. METHODS: Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30 days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model. RESULTS: A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3). CONCLUSION: Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.

Prognostic factors associated with unhealed perineal wounds post-proctectomy for perianal Crohn's disease: a two-centre study.

AIM: The aim of this work was to determine the factors associated with poor wound healing in patients with perianal Crohn's disease (pCD) who had undergone proctectomy in the era of biologic therapies. METHOD: Case record review was performed on 103 patients with pCD who underwent proctectomy at St Mark's Hospital, Harrow and the Western General Hospital, Edinburgh between 2005 and 2017. Healing rates at 6 and 12 months post-proctectomy were considered; univariate analysis was performed. RESULTS: Sixty out of 103 patients (58.3%) had failure of wound healing at 6 months and 41/103 (39.8%) at 12 months. In total, 63.1% (65/103) patients received biologic therapies prior to proctectomy; however, exposure to biologics was not a significant factor in predicting failure of wound healing at 12 months (infliximab p = 0.255; adalimumab p = 0.889; vedolizumab p = 0.153). Male gender was the only variable associated with poor wound healing at 12 months on univariate analysis (p = 0.017). A lower pre-operative C-reactive protein was associated with early wound healing at 6 months compared with at 12 months (p = 0.041) on univariate analysis. Other parameters not associated with rates of wound healing included smoking status, corticosteroid exposure, thiopurine exposure, number of previous biologics, perianal sepsis on MRI within the last 12 months, duration of CD prior to proctectomy and pre-operative albumin. CONCLUSION: More than a third of patients had unhealed wounds 12 months after proctectomy. We report that unhealed wounds are more common in male patients. Importantly, our results also suggest that exposure to biologics does not affect rates of wound healing.

A comparative multicentre study evaluating gluteal turnover flap for wound closure after abdominoperineal resection for rectal cancer.

BACKGROUND: The aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer. METHODS: Patients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016-2021) were compared to a multicentre cohort of primary closure (2000-2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis. RESULTS: Twenty-five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734-6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184). CONCLUSIONS: The uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap.

Perineal wound closure using gluteal turnover flap or primary closure after abdominoperineal resection for rectal cancer: study protocol of a randomised controlled multicentre trial (BIOPEX-2 study).

BACKGROUND: Abdominoperineal resection (APR) for rectal cancer is associated with high morbidity of the perineal wound, and controversy exists about the optimal closure technique. Primary perineal wound closure is still the standard of care in the Netherlands. Biological mesh closure did not improve wound healing in our previous randomised controlled trial (BIOPEX-study). It is suggested, based on meta-analysis of cohort studies, that filling of the perineal defect with well-vascularised tissue improves perineal wound healing. A gluteal turnover flap seems to be a promising method for this purpose, and with the advantage of not having a donor site scar. The aim of this study is to investigate whether a gluteal turnover flap improves the uncomplicated perineal wound healing after APR for rectal cancer. METHODS: Patients with primary or recurrent rectal cancer who are planned for APR will be considered eligible in this multicentre randomised controlled trial. Exclusion criteria are total exenteration, sacral resection above S4/S5, intersphincteric APR, biological mesh closure of the pelvic floor, collagen disorders, and severe systemic diseases. A total of 160 patients will be randomised between gluteal turnover flap (experimental arm) and primary closure (control arm). The total follow-up duration is 12 months, and outcome assessors and patients will be blinded for type of perineal wound closure. The primary outcome is the percentage of uncomplicated perineal wound healing on day 30, defined as a Southampton wound score of less than two. Secondary outcomes include time to perineal wound closure, incidence of perineal hernia, the number, duration and nature of the complications, re-interventions, quality of life and urogenital function. DISCUSSION: The uncomplicated perineal wound healing rate is expected to increase from 65 to 85% by using the gluteal turnover flap. With proven effectiveness, a quick implementation of this relatively simple surgical technique is expected to take place. TRIAL REGISTRATION: The trial was retrospectively registered at Clinicaltrials.gov NCT04004650 on July 2, 2019.

CT assessment of the quality of omentoplasty and its implications for perineal wound healing.

PURPOSE: This study was designed to examine the impact of an omentoplasty and its quality on pelviperineal morbidity after abdominoperineal resection (APR) for rectal cancer. METHODS: This was a retrospective single-centre study of consecutive patients undergoing APR for primary or recurrent rectal cancer between 2000 and 2018. Quality of omentoplasty was categorised (sufficient vs insufficient) based on postoperative CT scans. Main study endpoints were perineal wound healing and perineal hernia. RESULTS: This study included 100 patients: 16 with a sufficient omentoplasty, 16 with an insufficient omentoplasty, and 68 without omentoplasty. Rate of pelviperineal complications within 30 days was 44%, 69% and 64% (P = 0.283), and delayed wound healing at 3 months was 19%, 54% and 27%, respectively (P = 0.109). Sufficient omentoplasty was not significantly associated with less delayed healing in multivariable analysis (OR 0.597; 95% CI 0.149-2.397). An insufficient omentoplasty demonstrated significantly higher rates of delayed healing at 6 months (46% vs 14%; P = 0.016) and chronic perineal sinus at 12 months (31% vs 3%; P = 0.008) compared with no omentoplasty. CONCLUSION: This relatively small series suggest that even a sufficient omentoplasty, as determined by postoperative imaging, does not reduce pelviperineal morbidity after APR for rectal cancer. The methodology of CT-based assessment of an omentoplasty as well as the correlation with postoperative outcomes has to be validated in future studies.

Perineal Wound Closure Using Biological Mesh Following Extralevator Abdominoperineal Excision.

AIMS: This study aimed to describe the short-term perineal healing rates in patients with perineal reconstruction using a biological mesh following extralevator abdominoperineal excision (elAPE). METHODS: In a retrospective, descriptive single-centre cohort study, 88 consecutive patients treated with elAPE and perineal closure using a biological mesh between January 2011 and December 2015 were reviewed. All available data from electronic hospital records was collected. Patients were followed for 1 year following surgery and perineal wound status assessed at 3 months and at 1 year. RESULTS: In total, 63 patients were male and all but 8 patients were treated for primary rectal cancer. All patients but 3 had received radiotherapy prior to surgery. Multivisceral excisions were performed in 19 patients. Omentoplasty was performed in 55 patients and 3 different types of meshes were used during the study period. At 3 months, 58 patients (66%) had a healed perineum. No association was detected between patient, tumour or perioperative characteristics and perineal wound status at 3 months. At 1 year, 4 patients were deceased and among the remaining 84, the perineal wound was healed in 77 patients (92%). CONCLUSION: The use of biological meshes in perineal reconstruction following elAPE is feasible and safe, and the perineal wound is healed in the majority of the patients within 3 months.

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer.

BACKGROUND: Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR. METHODS: Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures. RESULTS: Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35-44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8-12 days). CONCLUSIONS: The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.

The LOREC APE registry: operative technique, oncological outcome and perineal wound healing after abdominoperineal excision.

AIM: The Low Rectal Cancer Development programme (LOREC) perineal wound healing registry was developed to record data on abdominoperineal excision (APE) for rectal cancer in colorectal units in England between 2012 and 2014, to understand current practice in operative technique and results. METHOD: Surgeons wishing to participate received secure Web-based access to the registry. Data were collected on preoperative staging, neoadjuvant treatment, operative details, histopathology, early outcome and follow up at 12 months. RESULTS: Forty-two units entered 266 patients. Of these, 172 (65%) patients underwent extralevator APE (ELAPE) and 94 had non-ELAPE procedures. On preoperative staging, 64% were mrT3/4, and 67% received neoadjuvant treatment. For the ELAPE group the perineal wound was closed primarily with mesh in 55% of patients, without mesh in 15% and with a flap in 21%. For non-ELAPE procedures, 54% of wounds were closed primarily without mesh, 29% primarily with mesh and 5% by a flap. Wound breakdown occurred in 30% and 31% of patients in the ELAPE and non-ELAPE groups, respectively, and was more common after neoadjuvant radiotherapy. Donor-site complications occurred in 17% of patients treated with a flap. Perineal morbidity was recorded in 11% of patients at 12 months. On histopathology, the resection margin was positive in 13% of patients in the ELAPE group and in 4% of patients in the non-ELAPE group. CONCLUSION: The LOREC registry provides a picture of current APE practice in England. ELAPE was used in two-thirds of patients but does not appear to confer any additional morbidity. Primary closure with mesh appeared as effective as flap reconstruction. The prevalence of an involved resection margin was lower than reported in many historical series but still remains high in the ELAPE group.

Perineal Wound Healing Following Abdominoperineal Resection of the Rectum.

OBJECTIVE: This study aimed to investigate perineal wound healing rates following abdominoperineal resection (APR) or extralevator abdominoperineal excision (ELAPE) for rectal cancer, with a focus on identifying associated risk factors and outcomes. METHODOLOGY: A retrospective analysis was conducted on patients undergoing APR or ELAPE for rectal cancer in a tertiary centre between 2013 and 2020. Data on demographics, comorbidities, surgical techniques, and perineal wound outcomes were collected and analyzed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 27.0, Armonk, NY). Statistical significance was set at p<0.05. RESULTS: A total of 87 patients were included, with a mean age of 64 years and the majority being male (66.7%). Neoadjuvant radiotherapy was administered in 87.4% of cases. Perineal wound complications were documented in 52 cases (59.8%), with major complications observed in 11 cases (12.6%). Healing within six months was achieved in 48 patients (55.2%), while 39 patients (44.8%) developed chronic perineal wounds. Logistic regression analysis revealed omentoplasty as a significant predictor of perineal wound healing rate showing a significant negative association (p=0.0289). CONCLUSION: Perineal wound healing rates following APR or ELAPE varied. While most patients achieved complete healing, chronic perineal wounds presented challenges. Omentoplasty was associated with lower odds of healing, suggesting the need for further investigation into its role. These findings underscore the importance of patient counselling and multidisciplinary management strategies to optimize outcomes in rectal cancer surgery.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). METHODS: We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. RESULTS: Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43-0.71; p < 0.01/Group B: OR 0.54, CI 0.17-1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35-0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12-1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39-4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90-3.08; p = 0.1) perineal complications in Group C. CONCLUSION: Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann's Operation or Intersphincteric Abdomino-Perineal Excision?

BACKGROUND AND AIMS: In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann's procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired. MATERIAL AND METHODS: A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann's procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival. RESULTS: There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann's procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann's procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann's procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien-Dindo 3-4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann's procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively. CONCLUSION: The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann's procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.

How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy--primary closure or flap repair? Best evidence topic (BET).

This best evidence topic was investigated according to a described protocol. The question posed was: should the irradiated perineal wound following abdominoperineal resection (APR) be closed with primary repair or a myocutaneous flap. Using the reported search 364 papers were found of which eight represented the best evidence to answer the clinical question. The conclusion drawn is that there is some limited evidence for recommending flap closure in abdominoperineal resection post radiotherapy. The best evidence available was from a systematic review of cohort studies and case series. Although no meta-analysis was performed, overall wound healing was improved using flap closure with a low frequency of flap necrosis. Other studies providing evidence were case-control series or cohort studies. Three papers prospectively compared vertical rectus abdominus muscle (VRAM) flap with primary closure; two of which demonstrated statistically significant improvement in complication rates with flap closure. Two retrospective case control series showed significant improvement in major wound complication rates in the flap group. Two studies retrospectively compared gracilis flap repair with primary closure and showed significantly lower incidence of major perineal complications. Most studies suffered from significant limitations, small sample sizes and no direct comparisons between matched groups with respect to type of anatomic flap, wound size, tumour recurrence or radiation dose. Whilst there is evidence that myocutaneous flap closure following APR in radiotherapy patients can reduce wound related complications, prospective randomized controlled trials are warranted.