Abstract: Perineal Reconstruction Following Anorectal Tumor Resection: An 18-Year Single-Center Experience (Plastic Surgery 2014)

Monday, October 13, 2014: 8:10 AM

Eric D Wang, MD , Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

Nicole Conkling, MD , Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

Xiaoti Xu, MD , Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

Hueylan Chern, MD , Department of Surgery, Division of Colorectal Surgery, University of California San Francisco, San Francisco, CA

Emily Finlayson, MD, MS , Department of Surgery, Division of Colorectal Surgery, University of California San Francisco, San Francisco, CA

Madhulika G Varma, MD , Department of Surgery, Division of Colorectal Surgery, University of California San Francisco, San Francisco, CA

Scott L Hansen, MD , Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

Robert D Foster, MD , Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

William Y Hoffman, MD , Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

Hani Sbitany, MD , Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, CA

Presentation PDF file

Background: Development of a chronic nonhealing perineal wound is a significant complication of abdominoperineal resection (APR), occurring in excess of 60% of these patients. The purpose of this study was to determine criteria for immediate flap coverage of the perineum following APR for anal and rectal cancer and examine our long-term cross-sectional surgical outcomes.

Methods: With institutional approval, we retrospectively analyzed a prospectively collected database of patients who underwent APR or pelvic exenteration for anorectal cancer with or without immediate flap closure of the perineum. We included demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction, and recovery. Outcomes were: successful wound healing, surgical complications necessitating intervention (admission or return to OR), infectious complications, and progression to chronic wounds. Descriptive statistics and multivariate logistic analyses were performed using JMP (v11, SAS Institute).

Results: 214 patients were identified from 1995-2013. 47 patients received flaps and had higher rates of recurrence and reoperation, active smoking, Crohn's disease, HIV, anal cancers and had higher AJCC Tumor stages (Table 1). 30-day complication rates were equivalent in the two cohorts (Table 2). There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher with flaps (55% vs. 41%, p=0.088). Infectious complications, readmissions, and operative revisions were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic wounds (23.3 vs. 8.5%, p=0.025). In multivariate analysis, Independent predictors of perineal complications included anal cancer, IORT, inflammatory bowel disease, as well as preoperative chemotherapy and radiation. Notably, selection for flap coverage was not identified as an independent predictor of complications.

Conclusion: In our large series, immediate flap coverage of the perineum was less likely progress to a chronic wound, but had higher postoperative infectious complication rates in comparison to closure without a flap. We attribute this to increased comorbidity in this cohort, reflecting the surgical decision-making in approaching these high-risk closures. In multivariate analysis, flap coverage was not identified as an independent predictor of complications. Further work will involve prospective validation of identified comorbidities as criteria for flap coverage.

24726 Perineal Reconstruction Following Anorectal Tumor Resection: An 18-Year Single-Center Experience