Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Impaired perineal wound healing has become a significant clinical problem after abdominoperineal resection for rectal cancer. The increased use of neoadjuvant radiotherapy and wider excisions might have contributed to this problem. OBJECTIVE: The primary aim of this systematic review with meta-analysis was to determine the impact of radiotherapy and an extralevator approach on perineal wound healing after abdominoperineal resection for rectal cancer. DATA SOURCES: In March 2014, electronic databases were searched. STUDY SELECTION AND INTERVENTIONS: Studies describing any outcome measure on perineal wound healing after abdominoperineal resection for rectal cancer were included. MAIN OUTCOME MEASURES: The primary end point was overall perineal wound problems within 30 days after conventional or extralevator abdominoperineal resection with or without neoadjuvant radiotherapy. Secondary end points were primary wound healing, perineal hernia rate, and the effect of biological mesh closure on perineal wound problems. RESULTS: A total of 32 studies were included. The pooled percentage of perineal wound problems after primary perineal wound closure in patients who did not undergo neoadjuvant radiotherapy was 15.3% (95% CI, 12.1-19.2) after conventional abdominoperineal resection and 14.8% (95% CI, 9.5-22.4) after extralevator abdominoperineal resection. After neoadjuvant radiotherapy, perineal wound problems occurred in 30.2% (95% CI, 19.2-44.0) after conventional abdominoperineal resection and in 37.6% (95% CI, 18.6-61.4) after extralevator abdominoperineal resection. Radiotherapy significantly increased perineal wound problems after abdominoperineal resection (OR, 2.22; 95% CI, 1.45-3.40; p < 0.001). After biological mesh closure of the pelvic floor following extralevator abdominoperineal resection with neoadjuvant radiotherapy, the percentage of perineal wound problems was 7.3% (95% CI, 1.5-29.3). LIMITATIONS: Heterogeneity was high for some analyses. CONCLUSION: Neoadjuvant radiotherapy significantly increases perineal wound problems after abdominoperineal resection for rectal cancer, whereas the extralevator approach seems not to be of significant importance.

Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: an algorithmic approach.

Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery. Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41-84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.

Reconstruction of the irradiated extended abdominoperineal excision (APE) defect for locally advanced colorectal cancer.

PURPOSE: There is substantial evidence for neoadjuvant chemoradiotherapy and extended abdominoperineal excision (APE) for improving local recurrence rates and overall survival for rectal carcinoma. While oncologic outcomes are improved, the large irradiated defect in the pelvic floor can potentiate poor operative outcomes. We describe a reconstructive option, the inferior gluteal artery myocutaneous (IGAM) transposition flap, which can enable wide tumour resections by providing substantial non-irradiated tissue bulk. METHODS: Ten consecutive patients underwent either standard APE with direct primary closure or extended APE with IGAM transposition flap reconstruction between 2007 and 2009 for mStage I-IIIC disease. Patients underwent staging computed tomography and pelvic magnetic resonance imaging, and neoadjuvant chemoradiotherapy after multi-disciplinary team discussion. Eight patients underwent extended APE and IGAM transposition flap reconstruction due to locally advanced stage of their carcinoma. Oncologic, reconstructive and post-operative outcomes were assessed. RESULTS: All cases demonstrated good closure of the APE defect, with no intra-operative perforations and no immediate operative complications. Histological margins were clear (R0) in all specimens, with mean closest distance to margin 10.8 mm (range 4-20 mm). Mean follow-up was 11.3 months, with no locoregional recurrences. There was no donor site morbidity and no perineal hernia; patients reported high degrees of satisfaction with aesthetic outcome. CONCLUSION: As the extended APE becomes increasingly utilized for rectal carcinoma, a reliable reconstructive option is increasingly important. The IGAM island transposition flap imports well-vascularized, non-irradiated tissue to reconstruct the defect, provides tissue bulk and potentiates good oncologic and reconstructive outcomes.

Long-term experience with transrectal and transperineal implantations of fiducial gold markers in the prostate for position verification in external beam radiotherapy; feasibility, toxicity and quality of life.

BACKGROUND AND PURPOSE: This study presents an overview of the experience with transrectal and transperineal implantations of fiducial markers for position verification in prostate radiotherapy, regarding the practical feasibility, procedure-related toxicity and influence on quality of life (QoL). MATERIAL AND METHODS: Since 2001, 914 patients scheduled for intensity-modulated radiotherapy (IMRT) have received gold markers in the prostate. The incidence of severe toxicity, defined by the CTCAE v3.0, was evaluated retrospectively. The influence on QoL was measured prospectively in 36 patients using a combination of three validated questionnaires: the Rand-36, the EORTC QLQ-C30(+3) and the prostate cancer-specific EORTC QLQ-PR25. Next, the incidence of marker migration was assessed. RESULTS: From 2001 to 2005, 402 patients received markers via the transrectal route. Two of these patients developed urosepsis (grade 3 toxicity). Since 2005, 512 patients received markers via the transperineal route. No grade 3 or 4 toxicity occurred in this group. No significant and clinically relevant differences were found in QoL between pre- and post-implant measures. In 5 patients marker migration led to discontinuation of the marker-based IMRT. CONCLUSIONS: Clinical use of transperineal-implanted fiducial gold markers for position verification in external beam radiotherapy for prostate cancer is a feasible and safe procedure without influencing patients' QoL.

Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects.

BACKGROUND: With the progressive use of more radical surgical resections and pre-operative chemo-radiotherapy for locally advanced anorectal cancers, there has become an increasing need for reconstructive options that import well-vascularised tissue of sufficient bulk to the perineum. We present our technique of inferior gluteal artery myocutaneous (IGAM) transposition flaps for reconstruction after extended abdomino-perineal excision (APE) for anorectal cancer. METHODS: Six consecutive male patients with T2/T3 rectal carcinoma underwent neoadjuvant chemo-radiotherapy followed by extended APE and immediate reconstruction with an islanded IGAM transposition flap. The operative technique and surgical outcomes were assessed with follow-up ranging from 3 to 18 months (median 5 months). RESULTS: In all cases, there were clear histological margins with no flap failures or partial flap losses, and no post-operative hernias. There were no major wound complications, with only one superficial breakdown associated with high body mass index (BMI) and adhesive tape allergy, treated with dressings alone. There was no donor site morbidity evident following flap harvest. CONCLUSION: The IGAM island transposition flap provides excellent tissue bulk, a large reliable skin paddle and a long pedicle that permits flexible positioning with tension free closure. Our successful results and high patient satisfaction make it a favourable option that should be considered when faced with this reconstructive challenge.

Radiotherapy for perianal Paget's disease: a case report.

BACKGROUND: Perianal Paget's disease was first described in 1893. Since then, fewer than 300 cases have been reported in the literature. It might be associated with an underlying malignancy. Most of the patients are treated with surgical excision, which is often mutilating and of variable efficacy. In the present report, we describe the case of an 80-year-old woman with perianal Paget's disease. She was treated at our institution with radiotherapy with curative intent. The pertinent literature is reviewed, and the controversies in diagnosis and management are discussed. CONCLUSIONS: Our single-case experience supports the opinion that radiotherapy is a viable treatment option with curative potential for patients with perianal Paget's disease. For the treatment of in situ disease, hypofractionated regimens to a total dose of 40-44 Gy and orthovoltage X-ray beams are recommended.

Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects.

BACKGROUND: Perineal wound complications after chemoradiotherapy and abdominoperineal resection (APR) for anorectal cancer occur in up to 60% of patients, including perineal abscess and wound dehiscence. Vertical rectus abdominis myocutaneous (VRAM) flaps have been used in an attempt to reduce these complications by obliterating the noncollapsible dead space with vascularized tissue and closing the perineal skin defect with nonirradiated flap skin. Many surgeons are reluctant to use VRAM flaps unless primary closure is not possible. STUDY DESIGN: All patients who underwent chemoradiotherapy and APR during a 12-year period at the University of Texas MD Anderson Cancer Center were retrospectively reviewed. Patient, tumor, and treatment characteristics and surgical complications and outcomes were compared between patients who underwent VRAM flap reconstruction of wounds that could have been closed primarily (flap group, n = 35) and those who had primary closure of the perineal wound (control group, n = 76). RESULTS: Overall, there were no significant differences in the incidence of perineal wound complications between the groups; the flap group had a significantly lower incidence of perineal abscess (9% versus 37%, p = 0.002), major perineal wound dehiscence (9% versus 30%, p = 0.014), and drainage procedures required for perineal/pelvic fluid collections (3% versus 25%, p = 0.003) than the control group had. Despite flap harvest and the need for donor site closure in the flap group, there was no significant difference in abdominal wall complications between groups during the study's mean patient followup of 3.8 years. CONCLUSIONS: VRAM flap reconstruction of irradiated APR defects reduces major perineal wound complications without increasing early abdominal wall complications. Strong consideration should be given to immediate VRAM flap reconstruction after chemoradiation and APR.

[Perineal wound complications following preoperative radiotherapy for rectal cancer]. / Perinealsårskomplikationer efter praeoperativ strålebehandling for rectumcancer.

INTRODUCTION: Every year, approximately 1200 new cases of rectal cancer are registered in Denmark. Preoperative radiation therapy alone or in combination with chemotherapy (chemo-radiation) is a gold standard in the treatment of patients with T3 and T4 tumours. Although it carries a good response rate, preoperative radiation is associated with significant morbidity including wound infection and delayed healing. The aim of this study is to clarify the effects of preoperative radiotherapy on wound healing in patients who underwent abdominoperineal excision and primary wound closure for rectum cancer. MATERIALS AND METHODS: In the period from 2001 to 2005, a total of 49 patients with rectum cancer underwent abdominoperineal excision with primary wound closure. Of these patients, 17 had preoperative radiotherapy. RESULTS: There was a significantly higher incidence of major wound complications in radiotherapy-treated patients compared to patients treated with operation alone (71% versus 26%). The median wound healing time was 122 days for patients treated with radiotherapy and 22 days for patients treated with operation alone. There was no difference in hospitalisation time following surgery. CONCLUSION: Preoperative radiotherapy for rectal cancer is an effective treatment modality in locally advanced rectum cancer but it carries a high risk of perineal wound complications. Alternative procedures to primary perineal wound closure should therefore be considered for these patients.

Persisting perianal ulcer after radiotherapy for anal cancer: recurrence of disease or late radiation-related complication?

We report the case of a 47-year-old HIV-negative male affected by a perianal ulcer which occurred after chemoradiation delivered for anal cancer. In spite of a negative biopsy the lesion was highly suspected to be a disease recurrence. Uncontrollable pain and anal stenosis were also present; abdominoperineal resection with a large excision of perianal tissues and reconstruction with bilateral musculocutaneous gracilis flaps was therefore performed. Histology did not confirm tumor recurrence. Thirteen months after surgery, the patient is still alive and free of disease. The introduction of radiotherapy and concomitant chemotherapy has revolutionized the treatment of anal cancer, avoiding demolitive surgery in a large subset of patients. Radionecrosis is an uncommon but potentially devastating event occurring in up to 10% of patients undergoing radiotherapy for anal cancer. It causes clinical (pain, anal stenosis, mucositis and diarrhea) and diagnostic problems (recurrence vs. benign post-attinic lesion). In the present article we review this uncommon complication, discuss the technical surgical aspects associated with a very large perianal tissue removal, and data of the most recent literature in this field.

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection.

BACKGROUND: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

The oblique rectus abdominis musculocutaneous flap: revisited clinical applications.

The authors present their experience with a previously described but infrequently used variation of the rectus abdominis myocutaneous flap. Skin paddles angled obliquely from the line of the rectus abdominis and toward the rib cage were successfully carried on periumbilical perforators from the inferior epigastric system. Skin paddle dimensions ranged from 6.5 to 12 cm in width and from 10 to 27 cm in length in 14 consecutive patients. In six of the 14 patients, the flap was used intraabdominally to obliterate radiated pelvic defects and to close radiated vaginal defects. Five flaps were placed externally to repair radiated wounds of the perineum, thigh, and trunk, and the remaining three cases were performed as free tissue transfers. One cadaver injection study was performed to redemonstrate the preferential flow of fluid in a superior-oblique direction from periumbilical perforators. Termed the oblique rectus abdominis musculocutaneous ("ORAM") flap, this flap variation has significant advantages in terms of ease of dissection and versatility over its flap cousins the vertical rectus abdominis musculocutaneous flap and the transverse rectus abdominis musculocutaneous flap.

Silver leaf nylon dressing to prevent radiation dermatitis in patients undergoing chemotherapy and external beam radiotherapy to the perineum.

PURPOSE: Silver-leaf nylon dressing (SLND) has been shown to have effective antimicrobial activity and to enhance healing in burns and skin grafts. The purpose of this study was to evaluate the value of SLND in preventing radiation dermatitis in patients undergoing radiotherapy to target volumes that included the perineum and concurrent chemotherapy. METHODS AND MATERIALS: Fifteen consecutive patients with either anal canal or gynecologic cancer were offered the SLND as a preventive intervention. The evaluation was based on standardized photographs taken at the end of treatment. A historical control group of 15 patients with the same neoplasms who received standard skin care was assessed in the same fashion. Ten observers unaware of the treatment intervention were enrolled in the evaluation of the skin changes. The Mann-Whitney U test was used to assess the statistical significance of the differences in the dermatitis scores between the two patient groups. RESULTS: The mean dermatitis score for controls was 2.62 (standard deviation, 0.48). The mean score for the SLND group was significantly lower at 1.16 (standard deviation, 0.40; p <0.0001). CONCLUSION: The results of this study suggest that SLND is effective in reducing radiation dermatitis, apparently because of its antibacterial properties.

HDR interstitial perineal implant for locally advanced or recurrent uterine cervix cancer.

PURPOSE: To evaluate whether high-dose-rate (HDR) interstitial perineal implants can effectively eradicate residual tumor or recurrent tumor in uterine cervix cancer after complete radiation treatment. MATERIALS AND METHODS: This method of treatment was commenced in January 2002, and four advanced stage and four uterine cervix cancer (UCC) recurrences were admitted for this study. All untreated stage II bulky mass and IIIB patients received 50 Gy external beam radiotherapy (EBR) to the whole pelvis prior to the interstitial perineal implant. No EBR was given to recurrent UCC. Brachytherapy was delivered using Martinez Universal Perineal Interstitial Template (MUPIT) and 192Ir HDR. This implant will only be done if residual disease on the parametria was bimanually palpable or was proven by CT scan or MRI. The dose of interstitial brachytherapy boost to the parametria was 17 to 30 Gy, and treatment days ranged from 42 to 64 days. Uterine recurrences were found on the uterine cervix and/or parametria. The dose delivered by this implant ranged from 6 to 16 Gy and encompassed either uterus or vaginal stump and both parametria. Total treatment days ranged from 1 to 2 days. RESULTS: This short-term study showed that almost all tumors were locally controlled when the study was closed (1 to 15 months). One distant metastasis was found. No significant morbidity has been identified until now. CONCLUSION: HDR 192Ir interstitial perineal implants were proven to be effective in eradicating tumor cells in advanced stage UCC and recurrent disease with no significant morbidity.

Perineal template interstitial brachytherapy salvage for recurrent endometrial adenocarcinoma metastatic to the vagina.

PURPOSE: To evaluate the use of interstitial brachytherapy salvage of recurrent endometrial adenocarcinoma metastatic to the vagina. METHODS: From September 1989 to February 1995, 15 patients with locally recurrent endometrial adenocarcinoma were treated with perineal template interstitial irradiation with low-dose-rate brachytherapy 192Ir/137Cs. Five of the 7 previously unirradiated patients received pelvic external beam radiation therapy (EBRT) of 45-50 Gy, with standard fractionation followed by an interstitial brachytherapy boost dose of 30 Gy (range 25 to 35 Gy). The other 2 patients received only brachytherapy of 40 Gy (palliative) and 50 Gy. Eight previously irradiated patients received only brachytherapy of 50 to 55 Gy. RESULTS: After a median follow-up of 47 months (range 14-81), the actuarial local control rate was 66.6%. The local control rate for patients treated with interstitial irradiation only was 64.3% and the local control rate for patients treated with interstitial irradiation + EBRT was 100%. Distant metastases occurred in 30.7% of the patients. Actuarial overall and disease-specific 5-year survival were 42.3 and 67.5%, respectively. Toxicity has been minimal, with 6 patients complaining of vaginal/rectal (RTOG) grade 1-3 complications (5 patients grade 1-2, 1 patient grade 3). CONCLUSIONS: These results suggest that perineal template interstitial irradiation (if possible with supplementary EBRT) is an effective alternative to radical or exenterative pelvic surgery for locally recurrent endometrial cancer. Excellent survival and local control rates can be achieved with low morbidity, especially if EBRT is added.

Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps.

PURPOSES: In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS: Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS: Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION: The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.

A simple technique for fabrication of transmission block for concomitant treatment of bilateral anterior inguinal lymphatics and pelvic/perineal structures.

The efficacy of transmission block technique with contiguous photon irradiation of inguinal as well as pelvic and perineal structures has been reported in literature. In this paper, a simple and accurate method for the proper fabrication of transmission block has been described and also demonstrated to be effective and useful. The procedures for a precise geometrical alignment and dose verification are also detailed.