Introduction: Surgical ablation of pelvic malignancy results in large soft tissue defects that can be problematic. The reported incidence of perineal wound complications after abdominoperineal resection (APR) ranges from 25-52%. Complications such as infection, fistulas, dehiscence, and development of chronic pelvic wounds, occur at a higher rate in the setting of prior radiation and recurrent disease. Various methods of perineal wound closure have been described, including open packing, primary closure, and tissue transfer (TT) in the form of muscle and fasciocutaneous flaps. While TT has been found effective in “rescue” situations of chronic wounds, its role has yet to be validated during the initial resection. At our institution, the use of TT at the time of an APR for a previously irradiated perineum has become standard practice. This study was designed to evaluate the effectiveness of flaps done at the time of APR in reducing wound morbidity.
Materials and Methods: A retrospective analysis of all patients who underwent an APR at the University of Washington from 1984 to 2003 was done. Patient demographics included age, sex, BMI (body mass index), smoking history, ASA (American Society of Anesthesiology) physical status, wound healing risks (i.e., steroids), diagnosis, disease status (i.e., stage of cancer), radiation history, and pelvic surgery history. Operative and postoperative variables included operative time, additional surgery during APR, administration of intra-operative radiation, and use of a flap. Postoperative details included wound healing at 6 months, occurrence of minor and major (donor site requiring wound care > 1 month, infection requiring intravenous antibiotics, re-operation or re-admission, and perineal fistula requiring wound care > 2 months) complications.
Results: 92 patients (mean age 56.6 yrs +/-15.1, 46% female) underwent APR and 23.9% (n=22) had a simultaneous TT. Patients undergoing TT were slightly younger (mean age 51.3 +/- 11.6, p=0.06), were more likely to have had cancer (91% vs 77%, p=0.05) and radiation therapy (86% vs 52%, p<0.01). The operative time was an hour longer in patients having TT (6.7 vs 5.6 hours, p=0.03) but did not result in longer hospitalizations (13 +/- 5.9 vs 12+/-7.6, p=0.5). 44.6% of patients had a wound healing complication with some patients having both major and minor complications (27.1% of patients had at least one major complication and 21.7% had at least one minor complication). 15% of all patients failed to heal their perineal wounds at 6 months. The rate of major complications was higher among patients with inflammatory bowel disease (43%) compared to 24% in patients with cancer (p=0.1), and there were no differences between patients who did and did not receive preoperative radiotherapy (26 vs 28%, p=0.8). Patients undergoing TT had a higher rate of all wound healing complications (59% vs 40%, p=0.1) and major wound healing complications (32% vs 26%, p=0.6). Despite the higher rate of wound complications in the TT group, only 9% (n=2) of patients undergoing TT failed to heal their wounds compared with 17% (n=12) of patients without TT (p=0.3). Once controlling for age, radiation therapy and cancer diagnosis, the odds of wound healing at six months were 75% greater if the patient had a TT (OR 1.75, 95% CI 0.3, 9.5).
Discussion: Flaps have been shown to be valuable in the treatment of chronic pelvic wounds. Their use in reconstruction after proctectomy in the setting of recurrent cancer and pre operative radiation still needs to be evaluated. Our data shows that patients who received flaps at the time of APR had a slightly higher incidence of major and minor complications, although these differences did not approach statistical significance. Most importantly, patients that received flaps at the initial APR had a higher incidence of ultimately healing their wounds with less chance of developing a chronic pelvic wound.
Conclusion: Patients undergoing TT at the time of APR have an insignificantly higher rate of transient wound healing complications, but have a higher likelihood of achieving a healed perineum.
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