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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1393_Библиотеки_им_академика_М_И_Перельмана.pdf
306 T. Holm
Fig. 17.8 Reconstruction of pelvic floor with biological mesh
Omentoplasty
Bowel obstruction, due to entrapment of the small bowel in the pelvic cavity, is not
infrequent after an APR. An omentoplasty filling out the pelvic cavity may reduce
this cause of postoperative small bowel obstruction. Therefore, and if the patient
has a large omentum, it is feasible to mobilize it from the transverse colon and from
the greater curvature of the stomach and to prepare an omentoplasty which can fill
out the empty pelvic cavity. Mobilization of the omentum and its placement in the
pelvic cavity to prevent injury to the small bowel during postoperative pelvic
irradiation is well known [19, 20]. Killeen and colleagues published a systematic
review on the use of omental pedicle flaps following proctectomy. They collected
17 Perineal Wound Post APR 307
data from 14 studies totaling 891 patients with a median follow-up of 13.5 months.
Mean rate of primary healing with omentoplasty was 67 versus 50% with no
omentoplasty. Mean time to healing in the former group was 24 versus 79 days in
the latter group. The authors concluded that: “Omental mobilization and buttressing
of primary perineal repair reduced perineal wound morbidity” [21].
Is There an Optimal Way to Reconstruct the Pelvic Floor and Perineum After an APR?
Butt and coll eagues preformed a systematic review of ELAPE including 27 series
and 963 patients. They compared the results of biomesh closures (149 patients) with
musculocutaneous flap closures (201 patients) and 578 patients with primary closure. Minor and major wound complications and perineal hernias were compared.
The results are shown in Table 17.1. The authors found no significant differences
regarding minor or major wound complications or perineal hernias in relation to
biomesh, muscle flaps, or primary closure and concluded that: “Despite several
techniques currently employed for perineal construction, it remains unclear as to
which is optimal” [22]. This systematic review does not include randomized controlled trials and it is highly likely that the size and nature of the defect might have
affected the choice of the closure technique and resultant complication rates.
Another review compared 255 patients undergoing flap repair to 85 patients
undergoing biological mesh repair and also found no significant difference in the
rates of perineal wound complications or perineal hernia formation [23].
In fact, there is no standard solution for pelvic floor reconstruction after APR and
as mentioned above the method used must be tailored according to the patient and
the extent of excision. It is recommended to assess each patient carefully within a
multidisciplinary team approach before surgery to determine the suitable type of
pelvic floor reconstruction and to establish collaboration with a plastic surgeon
team for reconstruction after the more wide excisions [24].
Table 17.1 Wound
complications in relation to
type of pelvic floor
reconstruction after ELAPE
Wound complication
Minor
(%)
Biomesh 27.5 13.4 3
Muscle flap 29.4 19.4 0
Primary
closure
17.1 6.4 1
Major
(%)
Perineal Hernia
(%)
308 T. Holm
Type of Complications
The goal after a more or less extensive excision of the perineum and pelvic floor
after an APR is to achieve a closed perineal wound without complications. Despite
improvements in surgical techniques, wound and patient care, perineal wound
complications are still common and account for significant morbidity. The main
complications from the perineal wound are superficial and deep infections, often
resulting in wound rupture and occasionally septicemia (Figs. 17.9, 10 and 11).
Delayed healing is a significant problem and the management of an open, deep
perineal wound is difficult with severe morbidity for the patient and with high costs
for the health care system. Features of the perineal wound predisposing to such
complications have been mentioned above and in addition, the vast area of dead
space in the pelvic cavity and the location of the wound in a pressure zone make it
more susceptible to necrosis and subsequent infection.
There are numerous reports with different outcomes concerning wound healing
after APR. A recent report from the LOREC group mirrors current practice for
patients with low rectal cance r in the UK [25]. Forty-two units entered 266 patients.
Of these 172 (65%) underwent extralevator APE (ELAPE) and 94 non-ELAPE.
After ELAPE the perineal wound was closed primary with mesh in 55%, without
mesh in 15% and with a flap in 21% of cases. After non-ELAPE 54% of wounds
Fig. 17.9 Superficial perineal infection
17 Perineal Wound Post APR 309
Fig. 17.10 Deep perineal infection with abscess
Fig. 17.11 Perineal wound rupture
310 T. Holm
were closed primarily without mesh, 29% primarily with mesh and 5% by a
flap. Wound breakdown occurred in 30% after ELAPE and 31% after non-ELAPE.
It was more common after neoadjuvant radiothera py. Donor site complications
occurred in 17% of flap cases. Perineal morbidity remained at 12 months in 11% of
the patients.
Perineal hernia is a late complication after APR and was reported originally by
Gregory and Muldoon in 1969 [26]. The extensive pelvic floor resection in ELAPE
is probably more conducive to perineal herniation (Fig. 17.12). The risk may
increase even further if the abdominal part of the operation is done by laparoscopy.
Sayers et al. recently reported a small study including 56 patients who underwent
ELAPE. Perineal hernia was the commonest complication (26%) and occurred in
nine (45%) of 20 patients who had a laparoscopic ELAPE [27]. These results differ
from those reported by Christensen et al. who did not see any perineal hernia in 24
patients after biological mesh repair [18].
Perineal entero-cutaneous bowel fistula is another late complication (Fig. 17.13).
Fortunately, this is rare and is difficult to treat when it occurs. The fistula most often
develops from the small bowel and usually in irradiated patients. It may occur as an
early or late complication, sometimes several years after the APR.
Fig. 17.12 Large perineal hernia
17 Perineal Wound Post APR 311
Fig. 17.13 Small bowel fistula to perineum
Management of Complications
Perineal wound complications after ELAPE differ significantly in severity and the
need for treatment is completely different in different situations. Table 17.2 gives a
brief summary of the different complications and their treatment.
Superficial infections (Fig. 17.9) are very common and can usually be treated
with simple debridement, cleansing, and wound dressings. Antibiotic therapy is
usually not indicated. The vast majority of these infec tions will heal within a few
weeks without persistent problems.
Deeper infections may appear as a deep subcutaneous infection or a pelvic
abscess with or without perineal wound breakdown (Fig. 17.14). The first priority is
to control infection. This may occasionally be done by drainage of the pelvic
abscess and antibiotics but usually the best treatment is to open up the wound and
apply intensive cleansing and debridement of the pelvic cavity and subcutaneous
Table 17.2 Perineal wound complications and treatment
Complication Treatment
Simple Infection Cleansing and Dressing Changes
Severe Infection/Wound Dehiscence Cleansing, debridement, lay open ± Vac treatment
Persistent Fistula/Sinus Surgical treatment
Perineal Hernia Surgical treatment
312 T. Holm
Fig. 17.14 Deep infection with necrosis and breakdown of perineal wound
tissues. Vac therapy may be applied in this situati on in order to improve cleansing
and induce tissue granulation (Fig. 17.15). When infection is under control, the best
approach is to wait for 3–6 months for secondary healing. Early secondary closure
after a deep infection and wound breakdown is generally futile and may induce a
new infection. However, surgery should be considered if the wound fails to heal
completely or a persistent sinus remains after six months. In this situation it is
crucial to evaluate the type and extent of the wound heali ng problem and to plan the
reconstructive procedure in detail. Timing of the operation is also very important.
17 Perineal Wound Post APR 313
Fig. 17.15 Vac therapy of perineal wound
High resolution magnetic resonance imaging (MRI) is an important adjunct to
clinical examination in a ssessing the extent of the complication. This is analogous
to its utility in preoperative staging of rectal cancers [28]. MRI is very useful to
distinguish an isolated perineal problem from a more complex problem, which may
involve small bowel adhesions to the pelvic floor or an enteric fistula to the perineal
wound or other organs. Such fistulae may also involve other organs, such as vagina,
bladder and urethra. The extent of the surgical procedure depends on the extent of
the problem and may involve only a perineal approach or a combined abdominal
and perineal approach.
A perineal approach is appropriate if the wound healing problem is confined to
the perineum. When the wound is clean with healthy granulating tissue one may
consider revision with primary suture or reconstruction with some form of musculocutaneous flap. Gluteus flaps are practical in this situation and uni- or bilateral
flaps may be used depending on the size of the unhealed defect. This type of
reconstruction is usually successful and the cosmetic result acceptable (Fig. 17.16).
In patients with a smaller and deeper unhealed sinus a gracilis muscle flap may be
more suitable. Reconstruction with a gluteus flap is best done with the patient in the
prone jack-knife position while the supine position often is better for a gracilis flap
reconstruction. It is important to take great care not to injure the small bowel when a
Fig. 17.16 Clean perineal wound, reconstruction with gluteus flap, and healed perineum
314 T. Holm
perineal approach only is used and the relation of the bowel to the bottom of the
wound must be established by MRI before surgery. If the distance from bowel to
wound is very short it may be safer to use a combined abdominal and perineal
technique.
The combined abdominoperineal operation must be used in situations where an
enteric fistula is present together with an unhealed perineal wound or if an
entero-cutaneous fistula to the perineum develops as a late complication
(Fig. 17.17). The extent of the abdominal surgery depends on the pathology and
may include simple adhesiolysis, small bowel resection, resection of the vagina and
all the way to pelvic exenteration in patients with complex fistulae, involving
bladder or urethra. Segments of fistulating bowel must be removed and anastomoses
made on healthy bowel. When the “neo-pelvic floor” is cleared from adhesions and
Fig. 17.17 Persistent perineal sinus with complex entero-cutaneous fistula
17 Perineal Wound Post APR 315
fistula tracts, and scar tissues excised, it is recommended to fill the pelvis with an
omental flap as described above. When the abdominal surgery is completed the
perineal reconstruction can be performed using a VRAM flap or uni- or bilateral
gluteus flaps.
Perineal hernias may develop as an early or late complication after APR and the
risk is probably related to the extent of pelvic floor removal. If the hernia is
symptomatic, which is often the case, it may cause pain and severely disable
everyday activities. Repair of perineal hernia remains ch allenging and there is no
consensus in the literature on the best approach. These patients should also be
examined clinically and by MRI to assess the extent of the perineal defect and the
contents of the hernia and the surgical approach must be tailored to the individual
patient. Our current approach is to repair small hernia without bowel involvement
by a perineal approach using mesh or gluteus flap. In hernias with bowel
involvement we use an abdominal approach with adhesiolysis, mesh repair of the
pelvic floor and omentoplasty. For large hernias with bowel involvement a combined abdominoperineal approach is used, combining adhesiolysis, omentoplasty
and gluteus muscle flap reconstruction. Most papers on perineal hernia are case
reports but one pooled analysis on 40 patients was published by Mjoli et al. in 2012.
They report a median time interval of 8 months between APR and surgical repair of
perineal hernia. The surgical approaches were perineal in 22 patients, open
abdominal in 11, open abdominoperineal in three , laparoscopic in five, and
laparoscopic-perineal in two patients. The recurrence rate was 5/25 for synthetic or
biological mesh, 6/12 for primary closure, and 2/6 for the remaining techniques.
The authors conclude that that the recurrence rates after primary perineal hernia
repair is lower with the use of a mesh or other assisted closure than with primary
suture repair.
Summary
Perineal complications after APR, conventional or ELAPE, are common and vary
significantly in complexity. The perineal wound is particularly prone to infectious
complications and wound rupture due to its location, size, and loss of tissue which
makes a tension-free repair difficult. The risk of wound complications increases
substantially after neoadjuvant radio- and radio-chemotherapy and as these treatments are increasingly used in patients with low rectal cancer it can be anticipated
that more patients will develop perineal wound problems after APR. Primary closure may still be an option in nonirradiated patients with small defects but as the
calculated risk for complications increases this is not sufficient and the surgeon
must plan for alternative procedures. The type of pelvic floor reconstruction is best
individualized and the decision should be based on several factors including patient
comorbidity, neoadjuvant treatment, and the extent of the pelvic floor defect. Good
collaboration with a skilled plastic and reconstructive surgeon team is invaluable.
Most perineal wound infections heal with proper local treatment. In patients with