BackgroundCurrent evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER.MethodsA retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).ResultsOne hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.ConclusionsThis study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.

Background Birth associated perineal trauma affects millions of women worldwide. The aim of the Perineal Assessment and Repair Longitudinal Study (PEARLS) was to evaluate if an enhanced, cascaded training programme improved implementation of evidence-based practise in perineal assessment and repair and reduced subsequent maternal morbidity. Methods PEARLS was a pragmatic matched pair cluster randomised controlled trial with 22 participating UK maternity units. Within each of the 11 matched pairs one unit was randomised to receive the intervention early (cluster A) and the other late (cluster B). Women sustaining a second-degree tear or episiotomy were eligible. Outcomes included pain on activity at 10–12 days postnatal, clinically reported outcomes by women and implementation of evidence-based surgical repair. Analysis was based on summary statistics at cluster level, using paired t-tests. Results 1470 and 2211 women were recruited in groups A and B respectively. No significant difference in mean primary outcome was noted between clusters that had received the intervention and those who had not (0.7% 95% CI (–10.1%, 11.4%), p = 0.89), with the overall percentage of women being 77% and 74% respectively. Improvement was seen in implementation of evidence-based perineal management. A significant reduction was noted in mean percentages of women reporting wound infections and needing suture removal in the early intervention clusters. Conclusion PEARLS is the first RCT to assess the impact of a ‘hands-on’ training package on implementation of evidence-based perineal trauma management and clinical outcomes for women. Findings will support improvements in clinical practise and women’s longer-term health.

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