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J Reconstr Microsurg 2022; 38(02): 089-095
DOI: 10.1055/s-0041-1729750
Original Article

Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons

Michael J. Stein
1   Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Canada
,
Aneesh Karir
2   Division of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, Canada
,
Melissa N. Hanson
3   Division of General Surgery, McGill University, Montreal, Canada
,
Naveen Cavale
4   Division of Plastic and Reconstructive Surgery, Kings College, London, United Kingdom
,
Alex M. Almoudaris
5   Division of General Surgery, University College Hospital, London, United Kingdom
,
Sophocles Voineskos
6   Division of Plastic and Reconstructive Surgery, McMaster University, Hamilton, Ontario, Canada
› Author Affiliations Funding This study was performed without external funding. None of the authors have commercial associations or financial disclosures that might pose a conflict of interest with information presented in this manuscript.
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Abstract

Background Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs).

Methods Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management.

Results Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%).

Conclusion A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.

Keywords

pelvic reconstruction - pelvic exenteration - abdominoperineal resection

Supplementary Material



Publication History

Received: 02 November 2020

Accepted: 14 March 2021

Article published online:
29 June 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Touran T, Frost DB, O'Connell TX. Sacral resection. Operative technique and outcome. Arch Surg 1990; 125 (07) 911-913
    CrossrefPubMedSearch in Google Scholar
  • 2 McAllister E, Wells K, Chaet M, Norman J, Cruse W. Perineal reconstruction after surgical extirpation of pelvic malignancies using the transpelvic transverse rectus abdominal myocutaneous flap. Ann Surg Oncol 1994; 1 (02) 164-168
    CrossrefPubMedSearch in Google Scholar
  • 3 Khoo AKM, Skibber JM, Nabawi AS. et al. Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery. Surgery 2001; 130 (03) 463-469
    CrossrefPubMedSearch in Google Scholar
  • 4 Kroll SS, Pollock R, Jessup JM, Ota D. Transpelvic rectus abdominis flap reconstruction of defects following abdominal-perineal resection. Am Surg 1989; 55 (10) 632-637
    PubMedSearch in Google Scholar
  • 5 Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 1988; 81 (01) 62-73
    CrossrefPubMedSearch in Google Scholar
  • 6 Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg 2009; 123 (01) 175-183
    CrossrefPubMedSearch in Google Scholar
  • 7 Butler CE, Gündeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 2008; 206 (04) 694-703
    CrossrefPubMedSearch in Google Scholar
  • 8 Chessin DB, Hartley J, Cohen AM. et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 2005; 12 (02) 104-110
    CrossrefPubMedSearch in Google Scholar
  • 9 Lefevre JH, Parc Y, Kernéis S. et al. Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneus flap on survival, recurrence, morbidity, and wound healing. Ann Surg 2009; 250 (05) 707-711
    CrossrefPubMedSearch in Google Scholar
  • 10 Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Nørgaard M, Laurberg S. Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 2009; 16 (01) 68-77
    CrossrefPubMedSearch in Google Scholar
  • 11 David S, William H, Paul B. et al. Immediate reconstruction of the perienal wound with gracilis muslce flaps following abdominoperineal resection and intraoperative radation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 1999; 6 (01) 33-37
    CrossrefPubMedSearch in Google Scholar
  • 12 Chong TW, Balch GC, Kehoe SM, Margulis V, Saint-Cyr M. Reconstruction of large perineal and pelvic wounds using gracilis muscle flaps. Ann Surg Oncol 2015; 22 (11) 3738-3744
    CrossrefPubMedSearch in Google Scholar
  • 13 Stein MJ, Karir A, Ramji M. et al. Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection☆ . J Plast Reconstr Aesthet Surg 2019; 72 (04) 565-571
    CrossrefPubMedSearch in Google Scholar
  • 14 Pang J, Broyles JM, Berli J. et al. Abdominal- versus thigh-based reconstruction of perineal defects in patients with cancer. Dis Colon Rectum 2014; 57 (06) 725-732
    CrossrefPubMedSearch in Google Scholar
  • 15 Luo S, Raffoul W, Piaget F, Egloff DV. Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg 2000; 105 (01) 171-173
    CrossrefPubMedSearch in Google Scholar
  • 16 di Summa PG, Matter M, Kalbermatten DF, Bauquis O, Raffoul W. Transabdominal-pelvic-perineal (TAPP) anterolateral thigh flap: A new reconstructive technique for complex defects following extended abdominoperineal resection. J Plast Reconstr Aesthet Surg 2016; 69 (03) 359-367
    CrossrefPubMedSearch in Google Scholar
  • 17 Hainsworth A, Al Akash M, Roblin P, Mohanna P, Ross D, George ML. Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps. Br J Surg 2012; 99 (04) 584-588
    CrossrefPubMedSearch in Google Scholar
  • 18 Boccola MA, Rozen WM, Ek EW, Teh BM, Croxford M, Grinsell D. Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects. J Plast Reconstr Aesthet Surg 2010; 63 (07) 1169-1175
    CrossrefPubMedSearch in Google Scholar
  • 19 Wagstaff MJ, Rozen WM, Whitaker IS, Enajat M, Audolfsson T, Acosta R. Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator flaps. Microsurgery 2009; 29 (08) 626-629
    CrossrefPubMedSearch in Google Scholar
  • 20 Devulapalli C, Jia Wei AT, DiBiagio JR. et al. Primary versus Flap closure of perineal defects following oncologic resection: a systematic review and meta analysis. Plast Reconstr Surg 2016; 137 (05) 1602-1613
    CrossrefPubMedSearch in Google Scholar
  • 21 Billig JI, Hsu JJ, Zhong L, Wang L, Chung KC, Kung TA. Comparison of effective cost and complications after abdominoperineal resection: primary closure versus flap reconstruction. Plast Reconstr Surg 2019; 144 (05) 866e-875e
    CrossrefPubMedSearch in Google Scholar
  • 22 Althumairi AA, Canner JK, Gearhart SL. et al. Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 2016; 18 (07) O260-O266
    CrossrefPubMedSearch in Google Scholar
  • 23 Johnstone MS. Vertical rectus abdominis myocutaneous versus alternative flaps for perineal repair after abdominoperineal excision of the rectum in the era of laparoscopic surgery. Ann Plast Surg 2017; 79 (01) 101-106
    CrossrefPubMedSearch in Google Scholar
  • 24 Manrique OJ, Rajesh A, Asaad M. et al. Surgical outcomes after abdominoperineal resection with sacrectomy and soft tissue reconstruction: lessons learned. J Reconstr Microsurg 2020; 36 (01) 64-72
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Jones H, Moran B, Crane S, Hompes R, Cunningham C. LOREC group. The LOREC APE registry: operative technique, oncological outcome and perineal wound healing after abdominoperineal excision. Colorectal Dis 2017; 19 (02) 172-180
    CrossrefPubMedSearch in Google Scholar
  • 26 Yang XY, Wei MT, Yang XT. et al. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis 2019; 21 (02) 138-155
    CrossrefPubMedSearch in Google Scholar
  • 27 Davidge KM, Raghuram K, Hofer SO. et al. Impact of flap reconstruction on perineal wound complications following ablative surgery for advanced and recurrent rectal cancers. Ann Surg Oncol 2014; 21 (06) 2068-2073
    CrossrefPubMedSearch in Google Scholar
  • 28 Sheckter CC, Shakir A, Vo H, Tsai J, Nazerali R, Lee GK. Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience. J Plast Reconstr Aesthet Surg 2016; 69 (11) 1506-1512
    CrossrefPubMedSearch in Google Scholar
  • 29 Jacombs AS, Rome P, Harrison JD, Solomon MJ. Assessment of the selection process for myocutaneous flap repair and surgical complications in pelvic exenteration surgery. Br J Surg 2013; 100 (04) 561-567
    CrossrefPubMedSearch in Google Scholar
  • 30 Proctor MJ, Westwood DA, Donahoe S. et al. Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery. Colorectal Dis 2020; 22 (05) 562-568
    CrossrefPubMedSearch in Google Scholar
  • 31 Howell AM, Jarral OA, Faiz O, Ziprin P, Darzi A, Zacharakis E. How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy--primary closure or flap repair? Best evidence topic (BET). Int J Surg 2013; 11 (07) 514-517
    CrossrefPubMedSearch in Google Scholar
  • 32 Chaudhry A, Oliver JD, Vyas KS. et al. Comparison of outcomes in oncoplastic pelvic reconstruction with VRAM versus omental flaps: a large cohort analysis. J Reconstr Microsurg 2019; 35 (06) 425-429
    Thieme ConnectPubMedSearch in Google Scholar
  • 33 Mericli AF, Martin JP, Campbell CA. An algorithmic anatomical subunit approach to pelvic wound reconstruction. Plast Reconstr Surg 2016; 137 (03) 1004-1017
    CrossrefPubMedSearch in Google Scholar
  • 34 Hardt J, Seyfried S, Weiß C, Post S, Kienle P, Herrle F. A pilot single-centre randomized trial assessing the safety and efficacy of lateral pararectus abdominis compared with transrectus abdominis muscle stoma placement in patients with temporary loop ileostomies: the PATRASTOM trial. Colorectal Dis 2016; 18 (02) O81-O90
    CrossrefPubMedSearch in Google Scholar
  • 35 Hardt J, Meerpohl JJ, Metzendorf MI, Kienle P, Post S, Herrle F. Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation. Cochrane Database Syst Rev 2019; 4 (04) CD009487
    PubMedSearch in Google Scholar
  • 36 Risk of bias instrument for cross-sectional surveys of attitudes and practices. Accessed April 7, 2021 at: https://www.evidencepartners.com/wp-content/uploads/2017/09/Risk-of-Bias-Instrument-for-Cross-Sectional-Surveys-of-Attitudes-and-Practices.pdf
    PubMed