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Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Intensified treatment for distal rectal cancer has improved oncological outcome, but at the expense of more perineal wound complications in patients undergoing an abdominoperineal resection (APR). The aim of this study was to analyse perineal wound healing after APR with primary perineal wound closure over time.

Method

All patients undergoing APR for primary rectal cancer with primary wound closure between 2000 and 2013 were included and analysed in three consecutive time periods. Both early (<30 days postoperatively) and late perineal wound complications were determined. Independent risk factors of early perineal wound complications were identified using multivariable analysis.

Results

A total of 136 patients were identified, of whom 129 patients underwent primary perineal wound closure. The use of neo-adjuvant (chemo)radiotherapy increased from 72 to 91 %, and the use of an extralevator approach increased from 9 to 19 %. The rate of early perineal wound complications increased from 18 to 31 % and was independently associated with an extralevator approach [odds ratio (OR) 3.17; 95 % confidence interval (CI) 1.16–8.66] and intra-operative perforation (OR 3.35; 95 % CI 1.06–10.57). Perineal wound complications had no impact on local recurrence or 3-year overall survival rate. During a median follow-up of 28 months [interquartile range (IQR) 14–56], a persistent presacral sinus was diagnosed in 10 %, and a perineal hernia occurred in 8 % of the patients.

Conclusion

The increased use of an extralevator APR for rectal cancer significantly increased the risk of perineal wound complications over time. Intra-operative perforation was also independently associated with impaired perineal wound healing.

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References

  1. Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN (2004) Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 91(2):210–216

    Article  CAS  PubMed  Google Scholar 

  2. Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23(36):9257–9264

    Article  PubMed  Google Scholar 

  3. den Dulk M, Putter H, Collette L et al (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer 45(7):1175–1183

    Article  Google Scholar 

  4. Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Int J Colorectal Dis 26(10):1227–1240

    Article  PubMed  Google Scholar 

  5. West NP, Finan PJ, Anderin C et al (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26(21):3517–3522

    Article  PubMed  Google Scholar 

  6. Fleming FJ, Pahlman L, Monson JR (2011) Neoadjuvant therapy in rectal cancer. Dis Colon Rectum 54(7):901–912

    Article  PubMed  Google Scholar 

  7. 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 

  8. West NP, Anderin C, Smith KJ, Holm T, Quirke P (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97(4):588–599

    Article  CAS  PubMed  Google Scholar 

  9. Musters GD, Buskens CJ, Bemelman WA, Tanis PJ (2014) Perineal wound healing after abdominoperineal resection for rectal cancer; a systematic review and meta-analysis. Dis Colon Rectum (In press)

  10. van Leersum NJ, Snijders HS, Wouters MW et al (2013) Evaluating national practice of preoperative radiotherapy for rectal cancer based on clinical auditing. Eur J Surg Oncol 39(9):1000–1006

    Article  PubMed  Google Scholar 

  11. Krol R, Hopman WP, Smeenk RJ, van Lin EN (2012) Increased rectal wall stiffness after prostate radiotherapy: relation with fecal urgency. Neurogastroenterol Motil 24(4):339–e166

    Article  CAS  PubMed  Google Scholar 

  12. O’Brien PC (2001) Radiation injury of the rectum. Radiother Oncol 60(1):1–14

    Article  PubMed  Google Scholar 

  13. Nanashima A, Arai J, Oyama S et al (2014) Associated factors with surgical site infections after hepatectomy: predictions and countermeasures by a retrospective cohort study. Int J Surg 12(4):310–314

    Article  PubMed  Google Scholar 

  14. De Broux E, Parc Y, Rondelli F et al (2005) Sutured perineal omentoplasty after abdominoperineal resection for adenocarcinoma of the lower rectum. Dis Colon Rectum 48(3):476–481

    Article  PubMed  Google Scholar 

  15. Hultman CS, Carlson GW, Losken A et al (2002) Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects: donor-site complications in 135 patients from 1975 to 2000. Ann Surg 235(6):782–795

    Article  PubMed Central  PubMed  Google Scholar 

  16. Howell AM, Jarral OA, Faiz O et al (2013) How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy—primary closure or flap repair? Best evidence topic (BET). Int J Surg 11(7):514–517

    Article  CAS  PubMed  Google Scholar 

  17. Petrie N, Branagan G, McGuiness C et al (2009) Reconstruction of the perineum following anorectal cancer excision. Int J Colorectal Dis 24(1):97–104

    Article  PubMed  Google Scholar 

  18. Bakx R, van Lanschot JJ, Zoetmulder FA (2004) Inferiorly based rectus abdominis myocutaneous flaps in surgical oncology: Indications, technique, and experience in 37 patients. J Surg Oncol 85(2):93–97

    Article  PubMed  Google Scholar 

  19. Loessin SJ, Meland NB, Devine RM et al (1995) Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps. Dis Colon Rectum 38(9):940–945

    Article  CAS  PubMed  Google Scholar 

  20. Foster JD, Pathak S, Smart NJ et al (2012) Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorectal Dis 14(9):1052–1059

    Article  CAS  PubMed  Google Scholar 

  21. Jensen KK, Rashid L, Pilsgaard B, Molle P, Wille-Jorgensen P (2014) Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to low wound complication and perineal hernia rates with minor movement limitations. Colorectal Dis 16(3):192–7

    Article  CAS  PubMed  Google Scholar 

  22. El-Gazzaz G, Kiran RP, Lavery I (2009) Wound complications in rectal cancer patients undergoing primary closure of the perineal wound after abdominoperineal resection. Dis Colon Rectum 52(12):1962–1966

    Article  PubMed  Google Scholar 

  23. Han JG, Wang ZJ, Wei GH et al (2012) Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 204(3):274–282

    Article  PubMed  Google Scholar 

  24. Bebenek M (2009) Abdominosacral resection is not related to the risk of neurological complications in patients with low-rectal cancer. Colorectal Dis 11(4):373–376

    Article  CAS  PubMed  Google Scholar 

  25. Toshniwal S, Perera M, Lloyd D, Nguyen H (2013) A 12-year experience of the Trendelenburg perineal approach for abdominoperineal resection. ANZ J Surg 83(11):853–8

    Article  PubMed  Google Scholar 

  26. Dormand EL, Banwell PE, Goodacre TE (2005) Radiotherapy and wound healing. Int Wound J 2(2):112–127

    Article  PubMed  Google Scholar 

  27. Haubner F, Ohmann E, Pohl F, Strutz J, Gassner HG (2012) Wound healing after radiation therapy: review of the literature. Radiat Oncol 7:162

    Article  PubMed Central  PubMed  Google Scholar 

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Conflict of interest

The authors have no conflicts of interest.

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Authors and Affiliations

  1. Department of Surgery, Academic Medical Centre, University of Amsterdam, G4, Post Box 22660, 1105 AZ, Amsterdam, The Netherlands

    Gijsbert D. Musters, Didi A. M. Sloothaak, Sapho Roodbeen, Willem A. Bemelman & Pieter J. Tanis

  2. Department of Surgery, Tergooiziekenhuizen, Post Box 10016, 1201 DA, Hilversum, The Netherlands

    Anna A. W. van Geloven

Authors
  1. Gijsbert D. Musters
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  2. Didi A. M. Sloothaak
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  3. Sapho Roodbeen
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  4. Anna A. W. van Geloven
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  5. Willem A. Bemelman
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  6. Pieter J. Tanis
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Correspondence to Pieter J. Tanis.

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Musters, G.D., Sloothaak, D.A.M., Roodbeen, S. et al. Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment. Int J Colorectal Dis 29, 1151–1157 (2014). https://doi.org/10.1007/s00384-014-1967-y

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  • DOI: https://doi.org/10.1007/s00384-014-1967-y

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