Perineal Wound Complications Following Extralevator Abdominoperineal Excision: Experience of a Regional Cancer Center

Abstract

Extralevator abdominoperineal excision (ELAPE) results in a large perineal defect which needs reconstruction by a flap or biological mesh. The incidence of perineal wound complications is thought to be higher following an ELAPE compared to conventional abdominoperineal excision (APE). WE aimed to analyze the perineal wound complications following ELAPE in our institution. This was a retrospective analysis of all consecutive patients who underwent an APE (conventional and ELAPE) procedure in our institution between 2012 and 2015. We retrieved the demographic data, treatment data, and pathological data from the case records. Reconstruction of the perineal defect after a prone perineal dissection was performed using a local muscle flap. The incidence of perinealwound complications, hospital stay, and time to initiate adjuvant chemotherapy was compared between the two groups. A total of 71 patients underwent APE over a period of 41 months of which 21 patients underwent ELAPE. The perineal dissection during ELAPE was done in the prone position in 18 patients and in the supine position in 3 patients. Perineal wound complications were seen in 9 patients (42%) who underwent ELAPE compared to 17 patients (34%) who underwent conventional APE (p = 0.52). The mean duration of hospital stay was significantly longer in patients who underwent ELAPE when compared to those who underwent conventional APE (22.9 ± 3.6 days vs 14.6 ± 1.0 days, p = 0.03). The median interval between ELAPE and initiation of adjuvant chemo was 54 days (range 32-120 days) compared to 50 days (range 30-100 days) in patients undergoing conventional APE. A delay in initiating adjuvant chemotherapy of more than 12 weeks was seen in 4 patients (19%) following ELAPE. The incidence of perineal wound complications following ELAPE in this study was comparable to that reported in literature. Although the hospital stay following ELAPE was significantly longer than that following conventional APE in our institution, it did not unduly prolong initiation of adjuvant chemotherapy. Improving the perineal reconstruction techniques and selecting patients who will benefit from ELAPE may help to reduce the wound complications.

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

“…This multicenter case series suggests that minimally invasive TpAPE is feasible with acceptable intraoperative complications, no short-term mortality and a 9% severe postoperative complication rate within 30 days. The postoperative major morbidity rate of 9% compares favorably to major morbidity rates between 10 and 30% and perineal wound infection ranging from 11 up to 50% reported in large series and meta-analysis, but the current study is limited by the small sample size and inherent case selection bias [21][22][23][24][25][26]. Five intraoperative complications were reported, four of which were related to wrong plane surgery with sequential perforation, urethral, and pelvic sidewall injury.…”

“…The postoperative major morbidity rate of 9% compares favorably to major morbidity rates between 10 and 30% and perineal wound infection ranging from 11 up to 50% reported in large series and meta-analysis, but the current study is limited by the small sample size and inherent case selection bias [ 21 – 26 ]. Five intraoperative complications were reported, four of which were related to wrong plane surgery with sequential perforation, urethral, and pelvic sidewall injury.…”

“…The wider and thereby more radical excision comes at the cost of a larger defect of the pelvic floor and skin [17][18][19][20]. Previous studies and meta-analyses have reported major morbidity rates between 10-30% and perineal wound healing problems from 11 up to 50% [21][22][23][24][25][26]. Especially in irradiated patients, perineal wound healing is problematic and sometimes requires primary or secondary reconstruction with musculocutaneous flaps to achieve perineal closure [26][27][28][29][30].…”

Continuous Negative Pressure Drainage with Intermittent Irrigation Leaded to a Risk Reduction of Perineal Surgical Site Infection Following Laparoscopic Extralevator Abdominoperineal Excision for Low Rectal Cancer

“… 4 , 7 It had been reported that the perineal wound complications were increased (range from 20% to 38%) after ELAPE. 8 , 9 A latest study reported that the rates of SSI after ELAPE was 26.3%. 10 In addition, preoperative radiotherapy and/or chemotherapy are often required for patients with low rectal cancer, which may also affect the healing of the surgical incision and increase the risk of SSI to approximately 31%.…”

The Impact of Complications on Short-Term Outcomes of Pelvic Peritoneum Reconstruction with Barbed Suture in Laparoscopic Rectal Resection for Rectal Cancer

“…However, laparoscopic surgery or open surgery in patients with rectal cancer after total mesorectal excision leaves a huge gap in the pelvic cavity. When the residual pelvic oor peritoneum is not suture, the small intestine will inevitably fall into the pelvic oor, causing the small intestine adhesion and increased the risk of intestinal obstruction [3]. Meanwhile, with increased intra-abdominal pressure and abdominal contents falling into the pelvic cavity, pelvic oor peritoneal hernia and delayed pelvic oor peritoneal healing will occur [4].…”