Surgical Outcomes after Abdominoperineal Resection with Sacrectomy and Soft Tissue Reconstruction: Lessons Learned

Abstract

Background Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution. Methods We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999–2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed. Results Forty-six patients underwent flap reconstruction following APRS—28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22–660 days). Half of our cohort (n = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively (p = 0.0076). Complete flap loss occurred in one patient. Conclusion The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.

Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection

“…9 Both radiochemotherapy and smoking did not show a higher rate of perineal complications; this is again representative of current available data published in other series. 15,21 However, smoking clinically showed a positive trend toward complications, suggesting how this condition should still be considered before embarking in complex perineal flap surgery. Interestingly, smoking did not show statistical significance toward flap-related complication rates.…”

“…Literature reports flap reconstruction in abdominoperineal resection (APR) ranging from 7% to 20%, 8,9 with primary closure showing a significant increase of perineal complications compared to flap closure. 10 The reconstructive armamentarium includes local, 5,[11][12][13] abdominal (vertical rectus abdominis myocutaneous (VRAM) or vertical deep inferior epigastric perforator), 9,[14][15][16] and thigh-based flaps (gracillis myocutaneous, anterolateral thigh (ALT), and posteromedial thigh). 5,6,[17][18][19][20] Pedicled VRAM are considered the gold standard after APR.…”

Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer

“…Complications of en bloc sacrectomy relate to the primary procedure undertaken, as well as the additional effect of the sacrectomy. In APR with flap reconstruction, complications, such as wound dehiscence, flap failure and perineal hernia, may have higher incidence when en bloc sacrectomy is additionally undertaken, with a higher transection level on the sacrum associated with higher perineal complication rates [ 38 , 39 , 40 ]. In fact, higher transections may be associated with higher all-cause morbidity, including physical function, pain, quality of life and bladder function [ 1 , 2 , 3 , 4 ], although other studies dispute this [ 13 , 18 , 41 ].…”

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

“…While multiple studies, including those by Manrique et al, 24 Jones et al, 25 Yang et al, 26 Chessin et al, 8 Butler et al, 7 and others, 27 28 advocate for the importance of flap reconstruction of the pelvis post-APR and -PEx, others warn that flap reconstruction should be approached with caution, and may only play a role in high risk patients.…”