Perineal Wound Complications after Abdominoperineal Resection

ABSTRACT

Perineal wound complications following abdominoperineal resection (APR) is a common occurrence. Risk factors such as operative technique, preoperative radiation therapy, and indication for surgery (i.e., rectal cancer, anal cancer, or inflammatory bowel disease [IBD]) are strong predictors of these complications. Patient risk factors include diabetes, obesity, and smoking. Intraoperative perineal wound management has evolved from open wound packing to primary closure with closed suctioned transabdominal pelvic drains. Wide excision is used to gain local control in cancer patients, and coupled with the increased use of pelvic radiation therapy, we have experienced increased challenges with primary closure of the perineal wound. Tissue transfer techniques such as omental pedicle flaps, and vertical rectus abdominis and gracilis muscle or myocutaneous flaps are being used to reconstruct large perineal defects and decrease the incidence of perineal wound complications. Wound failure is frequently managed by wet to dry dressing changes, but can result in prolonged hospital stay, hospital readmission, home nursing wound care needs, and the expenditure of significant medical costs. Adjuvant therapies to conservative wound care have been suggested, but evidence is still lacking. The use of the vacuum-assisted closure device has shown promise in chronic soft tissue wounds; however, experience is lacking, and is likely due to the difficulty in application techniques.

KEYWORDS

Abdominoperineal resection - perineal wound complication - wound management - tissue transfer - vacuum-assisted closure device

REFERENCES

• 1 Woods J E, Beart Jr R W. Reconstruction of nonhealing perineal wounds with gracilis muscle flaps.  Ann Plast Surg. 1983;  11 513-516
• 2 Kressner U, Graf W, Mahteme H, Pahlman L, Glimelius B. Septic complications and prognosis after surgery for rectal cancer.  Dis Colon Rectum. 2002;  45 316-321
• 3 Pollard C W, Nivatvongs S, Rojanasakul A, Ilstrup D M. Carcinoma of the rectum: profiles of intraoperative and early postoperative complications.  Dis Colon Rectum. 1994;  37 866-874
• 4 Rothenberger D A, Wong W D. Abdominoperineal resection for adenocarcinoma of the low rectum.  World J Surg. 1992;  16 478-485
• 5 Rosen L, Veiderheimer M, Coller J, Corman M. Mortality, morbidity, and patterns of recurrence after abdominoperineal resection for cancer of the rectum.  Dis Colon Rectum. 1982;  25 202-208
• 6 Papaconstantinou H T, Bullard K M, Rothenberger D A, Madoff R D. Salvage abdominoperineal resection after failed Nigro protocol: modest success, major morbidity.  Colorectal Dis. 2006;  8 124-129
• 7 Opelka F G. Unhealed perineal wound.  Clin Colon Rectal Surg. 2001;  14 65-68
• 8 Miles W E. Technique of the radical operation for cancer of the rectum.  Br J Surg. 1914;  2 292-305
• 9 Galandiuk S, Fazio V W. Postoperative irrigation-suction drainage after pelvic surgery. A prospective randomized trial.  Dis Colon Rectum. 1991;  34 223-228
• 10 Robles Campos R, Garcia Ayllon J, Parrila Paricio P et al.. Management of the perineal wound following abdominoperineal resection: prospective study of three methods.  Br J Surg. 1992;  79 29-31
• 11 Moreaux J, Horiot A, Barrat F, Mabille J. Obliteration of the pelvic space with pedicled omentum after excision of the rectum for cancer.  Am J Surg. 1984;  148 640-644
• 12 John H, Buchmann P. Improved perineal wound healing with the omental pedicle graft after rectal excision.  Int J Colorectal Dis. 1991;  6 193-196
• 13 De Broux E, Parc Y, Rondelli F, Dehni N, Tiret E, Parc R. Sutured perineal omentoplasty after abdominoperineal resection for adenocarcinoma of the lower rectum.  Dis Colon Rectum. 2005;  48 476-482
• 14 Bullard K M, Trudel J L, Baxter N N, Rothenberger D A. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure.  Dis Colon Rectum. 2005;  48 438-443
• 15 Artioukh D Y, Smith R A, Gokul K. Risk factors for impaired healing of the perineal wound after abdominoperineal resection of rectum for carcinoma.  Colorectal Dis. 2006;  9 362-367
• 16 Nilsson P J, Svensson C, Goldman S, Glimelius B. Salvage abdominoperineal resection in anal epidermoid cancer.  Br J Surg. 2002;  89 1425-1429
• 17 van der Wal B C, Cleffken B I, Gulec B, Kaufman H S, Choti M A. Results of salvage abdominoperineal resection for recurrent anal carcinoma following combined chemoradiation.  J Gastrointest Surg. 2001;  5 383-387
• 18 Stone H B, Coleman C N, Anscher M S, McBride W H. Effects of radiation on normal tissue: consequences and mechanisms.  Lancet Oncol. 2003;  4 529-536
• 19 Christian C K, Kwaan M R, Betensky R A, Breen E M, Zinner M J, Bleday R. Risk factors for perineal wound complications following abdominoperineal resection.  Dis Colon Rectum. 2005;  48 43-48
• 20 Whitlow C B, Opelka F G, Hicks T C, Timmcke A E, Beck D E. Perineal wound complications following proctectomy.  Perspect Colon Rectal Surg. 2000;  13 61-68
• 21 Shibata D, Hyland W, Busse P et al.. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum.  Ann Surg Oncol. 1999;  6 33-37
• 22 Tei T M, Stolzeburg T, Buntzen S, Laurberg S, Kjeldsen H. Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery.  Br J Surg. 2003;  90 575-580
• 23 Bakx R, Van Lanschot J JB, Zoetmulder F AN. Inferiorly based rectus abdominis myocutaneous flaps in surgical oncology: indications, technique, and experience in 37 patients.  J Surg Oncol. 2004;  85 93-97
• 24 Kapoor V, Cole J, Isik F F, Sinanan M, Flum D. Does the use of a flap during abdominoperineal resection decrease pelvic wound morbidity?.  Am Surg. 2005;  71 117-122
• 25 Doherty N S, Griffiths R J, Hakkinen J P, Scampoli D N, Milici A J. Post-capillary venules in the “milky spots” of the greater omentum are the major site of plasma protein and leukocyte extravasation in rodent models of peritonitis.  Inflamm Res. 1995;  44 169-177
• 26 Goldsmith H S, Griffith A L, Kupferman A, Catsimpoolas N. Lipid angiogenic factor from omentum.  JAMA. 1984;  252 2034-2036
• 27 Ellis H. The aetiology of post-operative abdominal adhesions. An experimental study.  Br J Surg. 1962;  50 10-16
• 28 Logmans A, Schoenmakers C H, Haensel S M et al.. High tissue factor concentration in the omentum, a possible cause of its hemostatic properties.  Eur J Clin Invest. 1996;  26 82-83
• 29 Hay J M, Fingerhut A, Paquet J C, Flamant Y. Management of the pelvic space with or without omentoplasty after abdominoperineal resection for carcinoma of the rectum: a prospective multicenter study. The French Association for Surgical Research.  Eur J Surg. 1997;  163 199-206
• 30 Shukla H S, Hughes L E. The rectus abdominis flap for perineal wounds.  Ann R Coll Surg Engl. 1984;  66 337-339
• 31 Taylor G I, Corlett R J, Boyd J B. The versatile deep inferior epigastric (inferior rectus abdominis) flap.  Br J Plast Surg. 1984;  37 330-350
• 32 Sinsel N K, Guelinckx P J. Peculiar indications for the pedicled or free rectus abdominis flap in reconstructive surgery. A review of our experience.  Acta Chir Belg. 1995;  95 289-296
• 33 Bartholdson L, Hulten L. Repair of persistent perineal sinuses by means of a pedicle flap of musculus gracilis. Case report.  Scand J Plast Reconstr Surg. 1975;  9 74-76
• 34 Baek S M, Greenstein A, McElhinney A J, Aufses Jr A H. The gracilis myocutaneous flap for persistent perineal sinus after proctocolectomy.  Surg Gynecol Obstet. 1981;  153 713-716
• 35 Serena T E, Nelson S, Corbran C. Becaplermin treatment of a dehisced pilonidal cystectomy wound results in rapid healing. Poster presented at: the American College of Surgeons 86th Annual Clinical Congress October 22-27, 2000 Chicago, IL;
• 36 Metz B J, Rubenstein M C, Levy M L, Metry D W. Response of ulcerated perineal hemangiomas of infancy to becaplermin gel, a recombinant human platelet-derived growth factor.  Arch Dermatol. 2004;  140 867-870
• 37 Hom D B, Manivel J C. Promoting healing with recombinant human platelet-derived growth factor-BB in a previously irradiated problem wound.  Laryngoscope. 2003;  113 1566-1571
• 38 Morykwas M J, Argenta L C. Nonsurgical modalities to enhance healing and care of soft tissue wounds.  J South Orthop Assoc. 1997;  6 279-288
• 39 Argenta L C, Morykwas M J. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience.  Ann Plast Surg. 1997;  38 563-576
• 40 Ferrell B A, Osterweil D, Christenson P. A randomized trial of low air loss beds for treatment of pressure ulcers.  JAMA. 1993;  269 494-497
• 41 Chen S Z, Li J, Li X Y, Xu L S. Effects of vacuum-assisted closure on wound microcirculation: an experimental study.  Asian J Surg. 2005;  28(3) 211-217
• 42 Miller Q, Bird E, Bird K, Meschter C, Moulton M J. Effect of subatmospheric pressure on the acute healing wound.  Curr Surg. 2004;  61 205-208