Skip to main content

Advertisement

SpringerLink
Log in

Reconstruction of the perineum following anorectal cancer excision

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Most patients with anal cancer receive chemoradiotherapy as first-line treatment. Persistent/recurrent tumours will subsequently require an abdomino-perineal resection (APR). A proportion of the 20,000 new cases of rectal carcinoma diagnosed in the UK each year receive neo-adjuvant chemoradiation and then an APR. Healing of the irradiated perineal bed is compromised, resulting in high morbidity. Reconstruction of the perineam with well-vasularised tissue is thought to enhance healing. This study investigates a series of 18 patients who underwent APR for anorectal cancer with flap reconstruction of their perineum.

Materials and methods

A retrospective analysis of all anorectal cancers requiring an APR and flap reconstruction was performed. Casenotes were reviewed and documentation made of risk factors putting them at increased risk of wound complications. Length of stay, morbidity and outcome variables including primary flap healing were recorded.

Results

Between November 2000 and October 2007, 18 cases were performed (M/F = 7:11), six for anal cancer and 12 for low rectal tumours. Pre-operative treatment was chemoradiotherapy in 14 (78%), radiotherapy alone in two (11%) and none in two (11%). Perineal reconstruction consisted of 14 vertical rectus abdominis myocutaneous flaps, three free latissimus dorsi flap and one transverse rectus abdominis myocutaneous flap. Mean hospital stay was 21.8 days (10–54 days). Complete healing was noted in 16 cases with the remaining two continuing to improve under current follow-up. There were no flap losses.

Conclusions

Despite most patients being treated with pre-operative radiotherapy, we have had significant success in obtaining primary healing of the perineal defect after APR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Whiteford MH, Stevens KR Jr., Oh S, Deveney KE (2001) The evolving treatment of anal cancer: how are we doing? Arch Surg 136(8):886–891

    Article  PubMed  CAS  Google Scholar 

  2. Ryan DP, Compton CC, Mayer RJ (2000) Carcinoma of the anal canal. N Engl J Med 342(11):792–800

    Article  PubMed  CAS  Google Scholar 

  3. Esiashvili N, Landry J, Matthews RH (2002) Carcinoma of the anus: strategies in management. Oncologist 7(3):188–199

    Article  PubMed  Google Scholar 

  4. Heidelberger C, Griesbach L, Montag BJ, Mooren D, Cruz O, Schnitzer RJ et al (1958) Studies on fluorinated pyrimidines. II. Effects on transplanted tumors. Cancer Res 18(3):305–317

    PubMed  CAS  Google Scholar 

  5. Bagshaw MA (1961) Possible role of potentiators in radiation therapy. Am J Roentgenol Radium Ther Nucl Med 85:822–833

    PubMed  CAS  Google Scholar 

  6. Vietti T, Eggerding F, Valeriote F (1971) Combined effect of x radiation and 5-fluorouracil on survival of transplanted leukemic cells. J Natl Cancer Inst 147(4):865–870

    Google Scholar 

  7. Nigro ND, Vaitkevicius VK, Considine B Jr (1974) Combined therapy for cancer of the anal canal: a preliminary report. Dis Colon Rectum 17(3):354–356

    Article  PubMed  CAS  Google Scholar 

  8. Epidermoid anal cancer: results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. UKCCCR Anal Cancer Trial Working Party. UK Co-ordinating Committee on Cancer Research. Lancet 348(9034):1049–1054

  9. Nilsson PJ, Svensson C, Goldman S, Glimelius B (2002) Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 89(11):1425–1429

    Article  PubMed  CAS  Google Scholar 

  10. Ferenschild FT, Vermaas M, Hofer SO, Verhoef C, Eggermont AM, de Wilt JH (2005) Salvage abdominoperineal resection and perineal wound healing in local recurrent or persistent anal cancer. World J Surg 29(11):1452–1457

    Article  PubMed  Google Scholar 

  11. Klebanoff SJ (1980) Oxygen metabolism and the toxic properties of phagocytes. Ann Intern Med 93(3):480–489

    PubMed  CAS  Google Scholar 

  12. Rudolph R, Vande Berg J, Schneider JA, Fisher JC, Poolman WL (1988) Slowed growth of cultured fibroblasts from human radiation wounds. Plast Reconstr Surg 82(4):669–677

    Article  PubMed  CAS  Google Scholar 

  13. Krueger WW, Goepfert H, Romsdahl M, Herson J, Withers RH, Jesse RH (1978) Fibroblast implantation enhances wound healing as indicated by breaking strength determinations. Otolaryngology 86(5):ORL–804–811

    PubMed  CAS  Google Scholar 

  14. Bernatchez SF, Parks PJ, Grussing DM, Matalas SL, Nelson GS (1998) Histological characterization of a delayed wound healing model in pig. Wound Repair Regen 6(3):223–233

    Article  PubMed  CAS  Google Scholar 

  15. Miles WE (1908) A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2:1812–1813

    Google Scholar 

  16. Miles WE (1914) Technique of the radical operation for cancer of the rectum. Br J Surg 2(6):292–305

    Article  Google Scholar 

  17. John H, Buchmann P (1991) Improved perineal wound healing with the omental pedicle graft after rectal excision. Int J Colorectal Dis 6(4):193–196

    Article  PubMed  CAS  Google Scholar 

  18. Manjoney DL, Koplewitz MJ, Abrams JS (1983) Factors influencing perineal wound healing after proctectomy. Am J Surg 145(1):183–189

    Article  PubMed  CAS  Google Scholar 

  19. Alpsan K, Singh A, Ahmad A (1980) Clinical comparison of perineal wound management. Dis Colon Rectum 23(8):564–566

    PubMed  CAS  Google Scholar 

  20. Altemeier WA, Culbertson WR, Alexander JW, Sutorius D, Bossert J (1974) Primary closure and healing of the perineal wound in abdominoperineal resection of the rectum for carcinoma. Am J Surg 127(2):215–219

    Article  PubMed  CAS  Google Scholar 

  21. Kim HK, Jessup JM, Beard CJ, Bornstein B, Cady B, Stone MD et al (1997) Locally advanced rectal carcinoma: pelvic control and morbidity following preoperative radiation therapy, resection, and intraoperative radiation therapy. Int J Radiat Oncol Biol Phys 38(4):777–783

    Article  PubMed  CAS  Google Scholar 

  22. Radice E, Nelson H, Mercill S, Farouk R, Petty P, Gunderson L (1999) Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies. Br J Surg 86(3):349–354

    Article  PubMed  CAS  Google Scholar 

  23. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA (2005) Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 48(3):438–443

    Article  PubMed  Google Scholar 

  24. Holm T, Lyung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238

    Article  PubMed  CAS  Google Scholar 

  25. Anthony JP, Mathes SJ (1990) The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closure. Arch Surg 125(10):1371–1376 (discussion 1376–1377)

    PubMed  CAS  Google Scholar 

  26. Bartholdson L, Hulten L (1975) Repair of persistent perineal sinuses by means of a pedicle flap of musculus gracilis. Case report. Scand J Plast Reconstr Surg 9(1):74–76

    Article  PubMed  CAS  Google Scholar 

  27. Pezim ME, Wolff BG, Woods JE, Beart RW Jr, Ilstrup DM (1987) Closure of postproctectomy perineal sinus with gracilis muscle flaps. Can J Surg 30(3):212–214

    PubMed  CAS  Google Scholar 

  28. Baek SM, Greenstein A, McElhinney AJ, Aufses AH Jr (1981) The gracilis myocutaneous flap for persistent perineal sinus after proctocolectomy. Surg Gynecol Obstet 153(5):713–716

    PubMed  CAS  Google Scholar 

  29. Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, Steele G Jr et al (1999) 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 6(1):33–37

    Article  PubMed  CAS  Google Scholar 

  30. Yii NW, Niranjan NS (1996) Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 49(8):547–554

    Article  PubMed  CAS  Google Scholar 

  31. Hashimoto I, Nakanishi H, Nagae H, Harada H, Sedo H (2001) The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume. Plast Reconstr Surg 108(7):1998–2005

    Article  PubMed  CAS  Google Scholar 

  32. Luo S, Raffoul W, Piaget F, Egloff DV (2000) Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg 105(1):171–173

    Article  PubMed  CAS  Google Scholar 

  33. Shukla HS, Hughes LE (1984) The rectus abdominis flap for perineal wounds. Ann R Coll Surg Engl 66(5):337–339

    PubMed  CAS  Google Scholar 

  34. Tobin GR, Day TG (1988) Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 81(1):62–73

    Article  PubMed  CAS  Google Scholar 

  35. Skene AI, Gault DT, Woodhouse CR, Breach NM, Thomas JM (1990) Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap. Br J Surg 776:635–637

    Article  Google Scholar 

  36. Erdmann MW, Waterhouse N (1995) The transpelvic rectus abdominis flap: its use in the reconstruction of extensive perineal defects. Ann R Coll Surg Engl 77(3):229–232

    PubMed  CAS  Google Scholar 

  37. Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H (2003) Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br J Surg 90(5):575–580

    Article  PubMed  CAS  Google Scholar 

  38. Buchel EW, Finical S, Johnson C (2004) Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg 52(1):22–26

    Article  PubMed  Google Scholar 

  39. Kapoor V, Cole J, Isik FF, Sinanan M, Flum D (2005) Does the use of a flap during abdominoperineal resection decrease pelvic wound morbidity? Am Surg 71(2):117–122

    PubMed  Google Scholar 

  40. Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E (2005) Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 92(4):482–486

    Article  PubMed  CAS  Google Scholar 

  41. Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J et al (2005) Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 12(2):104–110

    Article  PubMed  Google Scholar 

  42. Gurlek A, Miller MJ, Amin AA, Evans GR, Reece GP, Baldwin BJ et al (1998) Reconstruction of complex radiation-induced injuries using free-tissue transfer. J Reconstr Microsurg 14(5):337–340

    Article  PubMed  CAS  Google Scholar 

  43. Kroll SS, Robb GL, Reece GP, Miller MJ, Evans GR, Baldwin BJ et al (1998) Does prior irradiation increase the risk of total or partial free-flap loss? J Reconstr Microsurg 14(4):263–268

    Article  PubMed  CAS  Google Scholar 

Download references

Conflicts of interest statement

None

Author information

Authors and Affiliations

  1. Salisbury NHS Foundation Trust, Salisbury, Wiltshire, SP28BJ, UK

    Nicola Petrie, Graham Branagan, Caroline McGuiness, Shaun McGee, Clare Fuller & Helen Chave

Authors
  1. Nicola Petrie
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Graham Branagan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Caroline McGuiness
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shaun McGee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Clare Fuller
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Helen Chave
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Helen Chave.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Petrie, N., Branagan, G., McGuiness, C. et al. Reconstruction of the perineum following anorectal cancer excision. Int J Colorectal Dis 24, 97–104 (2009). https://doi.org/10.1007/s00384-008-0557-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-008-0557-2

Keywords

Search

Navigation