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A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis

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Abstract

Background

To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis.

Methods

An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed.

Results

Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap.

Conclusions

Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the “best” option, and tailoring to the individual remains a critical factor.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Authors and Affiliations

  1. Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy

    C. G. Riva, M. Vitellaro, G. Bonitta & E. Rausa

  2. School of Medicine, Trinity College Dublin, Dublin, Ireland

    M. E. Kelly

  3. The Trinity St. James’s Cancer Institute, Dublin, Ireland

    M. E. Kelly

  4. Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy

    M. Rottoli

  5. General Surgery, Istituto Clinico Sant’Ambrogio, Milan, Italy

    A. Aiolfi

  6. Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA

    D. Ferrari

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Supplementary file1 Electronic systematic searches (DOCX 12 KB)

Supplementary file2 Distribution of age and sex across the treatments (TIF 153 KB)

10151_2023_2868_MOESM3_ESM.tif

Supplementary file3 Node-split analysis for A, Primary healing of perineal wound; B, perineal hernia; C, incidence of perineal complications; D, reintervention related to perineal wound; (TIF 341 KB)

10151_2023_2868_MOESM4_ESM.tiff

Supplementary file4 Network geometry for studies reporting E, incidence of perineal infection; F, abscess/collection; G, dehiscence; and H, development of chronic sinus (TIFF 213 KB)

10151_2023_2868_MOESM5_ESM.tiff

Supplementary file5 Forest plots of network meta-analysis estimates the risk ratio for E, incidence of perineal infection; F, abscess/collection; G, dehiscence; and H, development of chronic sinus (TIFF 4813 KB)

10151_2023_2868_MOESM6_ESM.tiff

Supplementary file6 A rank plot created using the rankogram function from the gemtc R package applied to the three surgical approaches illustrating empirical probabilities that each treatment is ranked first through fourth (left to right) for E, incidence of perineal infection; F, abscess/collection; G, dehiscence; and H, development of chronic sinus (TIFF 4565 KB)

Supplementary file7 (DOCX 368 KB)

Supplementary file8 (DOCX 23 KB)

Supplementary file9 (DOCX 21 KB)

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Riva, C.G., Kelly, M.E., Vitellaro, M. et al. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 27, 1351–1366 (2023). https://doi.org/10.1007/s10151-023-02868-1

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