perineal wound closure after abdominoperineal resection

www.downstatesurgery.org
Christopher Lau
April 28, 2011
SUNY Downstate Medical Center
Richmond University Medical Center
PERINEAL WOUND CLOSURE AFTER
ABDOMINOPERINEAL RESECTION
www.downstatesurgery.org
HISTORY
49 year old male who was found to have a
rectal mass upon workup for anemia and
bloody stool in August 2010
 Presented with intermittent episodes of blood
streaked stool for 2 years
 Found to have Hb/Hct of 6.2/24.8
 No nausea, vomiting, abdominal pain, or
significant weight loss

www.downstatesurgery.org
HISTORY
PMH: none
 Allergy: NKDA
 Medications: none
 Family Hx: Father – pharyngeal cancer
 Social Hx: Alcohol abuse for over 30 years,
in rehab

www.downstatesurgery.org
PHYSICAL EXAM
Gen: AAOx3, NAD
 HEENT: no icterus, no pallor, moist mucosa
 CVS: S1S2 normal, RRR
 Chest: CTA b/l
 Abd: soft, nontender, nondistended, normal
BS, no masses palpable
 Rectal: hard firm mass, blood
 No palpable lymphadenopathy

www.downstatesurgery.org
LABS




WBC
Hgb
Hct
Plt
5.2
10
31.2
168













Na
K
Cl
CO2
BUN
Cr
Glu
Ca
134
4.1
102


26
7
0.6
208
9.2


T prot
Alb
AST
ALT
Alk phos
T bili
7.1
3.9
20
19
90
PT
PTT
INR
11.5
23.4
1.03
0.4
www.downstatesurgery.org
IMAGING
Initial CT with long segment and circumferential thickening of rectum
www.downstatesurgery.org
MANAGEMENT COURSE
Colonoscopy revealed a 14cm long lesion
extending from near the anal canal to
sigmoid colon
 Pathology:

 Transverse
polyp – TVA
 Sigmoid polyp – TVA with foci of
adenocarcinoma
 Rectal mass - adenocarcinoma
www.downstatesurgery.org
MANAGEMENT COURSE
The patient underwent neoadjuvant
chemoradiation (49Gy)
 November 2010 - Rectal exam under
anesthesia with rigid proctoscopy after
treatment revealed minimal response to
neoadjuvant treatment
 Mass was 1-1.5cm from the dentate line, friable,
hard, and circumferential
 The pt chose to delay surgery to go on vacation
and underwent resection in February 2011

www.downstatesurgery.org
IMAGING
Repeat CT after neoadjuvant therapy
www.downstatesurgery.org
OPERATION







Bilateral ureteral stents placed by Urology
Laparoscopic assisted APR with permanent colostomy
Left colon, sigmoid and rectum were mobilized
laparoscopically for the TME
We noted a structure on the left side of the pelvis which
possibly represented ureter
Abdomen was opened, ureter was identified and followed
down
The TME was completed in an open fashion from above
and below
Abdominal wound was closed and permanent colostomy
was fashioned
www.downstatesurgery.org
PERINEAL CLOSURE
The peritoneum was closed near the pelvic
inlet with a running suture
 A 20 fr foley catheter and 1 inch penrose
drain were placed in the perineal wound
 The wound was closed in layers

 Deep
levator muscle and subcutaneous tissue
 2 layers of subcutaneous tissue
 Skin closed with 0 nylon mattress sutures
www.downstatesurgery.org
POSTOP COURSE

POD 2:
Colostomy producing gas
 NG tube removed, started clears
 Ureteral stents removed


POD 3:


Colostomy producing stool
POD 4:
Diet advanced
 Edges of perineal wound ischemic
 Perineal wound debrided

www.downstatesurgery.org
POSTOP COURSE

POD 5:
 Bottom
of midline abdominal wound opened for
wound infection

POD 6:
 B/L
upper lobe pneumonia
 Appropriate antibiotics given

POD 11:
 Tolerating
regular diet
www.downstatesurgery.org
POSTOP COURSE

POD 12:
 Perineal
wound debrided further
 Foley and penrose removed

POD 13:
 VAC

dressing placed
POD 21:
 OR
debridement of wound
www.downstatesurgery.org
POSTOP COURSE

POD 25:
 Abdominal
wound closed by delayed primary
 Discharged home

POD 34:
 Seen
in clinic
 Abdominal wound healed
 Perineal wound clean and granulating
www.downstatesurgery.org
PATHOLOGY

T3N1Mx
 Invasive
mucinous adenocarcinoma
 Proximal, distal, and radial margins free of tumor
 3/19 lymph nodes positive
 No lymphovascular invasion

Stage IIIB
www.downstatesurgery.org
PERINEAL WOUND CLOSURE AFTER
ABDOMINOPERINEAL RESECTION
www.downstatesurgery.org
INTRODUCTION
Rectal cancer is a significant source of
morbidity and mortality in the US
 >40,000 cases diagnosed each year
 Cure is rarely achieved without R0 resection
 Mainstay of treatment is surgical excision
with TME and chemoradiation
 However, morbidity from perineal wound
complications occurs in up to 30-40%

Paun BC et al. Postoperative complications following surgery for rectal cancer. Ann Surg. 2010 May;251(5):807-18.
www.downstatesurgery.org
COMPLICATIONS OF RECTAL SURGERY
Wound infection 7%
 Anastomotic leak 11%
 Pelvic sepsis 12%
 Postop death 2%
 Fecal incontinence
 Perineal wound infection
 Perineal wound breakdown
 Perineal Fistula

Paun BC et al. Postoperative complications following surgery for rectal cancer. Ann Surg. 2010 May;251(5):807-18.
www.downstatesurgery.org


Most comon
operations are LAR
and APR
Neoadjuvant
chemoradiation has
improved local control
and sphincter
preservation in low
rectal tumors
LA
R
AP
R
www.downstatesurgery.org
EFFECTS OF RADIATION



Capillary obliteration and fibrosis result in impaired
tissue oxygenation, altered cellular immune
mechanisms and decreased fibroblast activity
Long-lasting effects
Salvage APR for anal cancer




25-70% wound complications
Wound healing time >3 months in 66%
Radiation increases rate of wound complications 2-10
times
Perineal wound complications after APR for rectal
cancer are 35-41% with radiation
Nilsson PJ. Omentoplasty in abdominoperineal resection: a review of the literature using a systematic approach. Dis Colon Rectum. 2006
Sep;49(9):1354-61.
Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009 Oct;11(8):806-16.
www.downstatesurgery.org
OPTIONS FOR PERINEAL CLOSURE





Open drainage
Suture of perineal wound and pelvic peritoneum
Suture of perineal wound without suture of pelvic
peritoneum
Use of mesh sling to close peritoneum
Placement of various drains






Open drains
Closed suction drains
Vacuum devices
Antibiotic impregnated products
Omentoplasty
Myocutaneous flap reconstruction
www.downstatesurgery.org
WHAT SHOULD WE DO?
There have been no good, randomized,
controlled trials comparing the various
methods of perineal closure available today
 There are many case series that support the
effectiveness of various techniques
 Practice guidelines for any particular closure
method cannot be given with the current
studies available

www.downstatesurgery.org
HISTORY
In traditional surgery, primary healing was
considered impossible
 In the 1970’s, several studies compared open
drainage vs. primary closure of the perineum

Incidence of primary wound healing was higher with
primary closure (45-49%)
 Incidence of persistent sinuses and unhealed
wounds was lower
 Wounds that were closed primarily and then
reopened secondary to infection had similar results
to wounds that were left open primarily

Irvin TT, Goligher JC. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum. Br J
Surg. 1975 Apr;62(4):287-91.
Terranova O et al. Management of the perineal wound after rectal excision for neoplastic disease: a controlled clinical trial. Dis Colon Rectum.
1979 May-Jun;22(4):228-33.
www.downstatesurgery.org
TYPE OF DRAINAGE TUBE







186 patients randomized to receive passive (n=96) or
closed suction (n=90) drainage
Followed for 12 months
Rate of healing at 1 month was significantly lower in the
passive drainage group, 61% vs. 75% (p<0.05)
At 3 months the rate was similar, 81 vs. 84%
At 12 months the rate of fistula, secondary reopening and
nonhealing was similar as well
Results suggest closed suction drainage should be used
after APR
Others comparing open packing vs. simple drain vs.
closed suction drain vs. closed suction drain + irrigation
system found similar results
•Fingerhut A et al. Passive vs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma. A
multicenter, controlled trial. The French Association for Surgical Research. Dis Colon Rectum. 1995 Sep;38(9):926-32.
•Hartz RS et al. Healing of the perineal wound. Arch Surg. 1980 Apr;115(4):471-4.
www.downstatesurgery.org
CLOSE THE PERITONEUM?
Leaving peritoneum open allows small bowel to
descend into pelvis
 Creates difficulty if pt develops SBO or
recurrence of tumor
 Risk of evisceration if perineal wound opens
 Radiation can affect small bowel
 Closing the peritoneum creates an empty space
in the pelvis


May lead to higher rate of infection
Robles R et al. Management of the perineal wound following abdominoperineal resection: prospective study of three methods. Br J Surg. 1992
Jan;79(1):29-31.
www.downstatesurgery.org
LOCAL ANTIBIOTICS IN THE PERINEAL WOUND
Antibiotic concentrations in the sacral wound
given IV or PO are negligible
 Local application achieves high
concentrations
 Use of gentamicin impregnated collagen
fleeces to improve wound healing
 97 patients randomized to 2 groups

 All
had primary closure in layers with a drain
 Randomized to either with or without gentamicin
impregnated collagen fleece
Gruessner U et al; Septocoll Study Group. Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen
fleeces after abdominoperineal excision of rectal cancer. Am J Surg. 2001 Nov;182(5):502-9.
www.downstatesurgery.org
LOCAL ANTIBIOTICS IN THE PERINEAL WOUND



Most common
organisms were staph,
enterococcus,
pseudomonas
83-100% sensitive to
gentamicin
Lower rate of perineal
infection in Genta group,
6 vs. 21% (p<0.05)

Treated by simple
opening of perineal
wound
Primary perineal wound
healing 88 and 75%
Gruessner U et al; Septocoll Study Group. Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen
fleeces after
abdominoperineal excision of rectal cancer. Am J Surg. 2001 Nov;182(5):502-9.
(p=0.124)

www.downstatesurgery.org
OMENTOPLASTY




Greater omentum can be used to fill the dead space
in the pelvis after APR
Brings well vascularized, non-irradiated tissue
No randomized trials are available
Recent review of the literature found 4 cohort studies
and 6 case series




Total 366 patients
Only 2 of the cohort studies had adequate controls
Cohort studies found statistically significant
improvement in healing rates and complication rates
No adequate evidence for or against omentoplasty
Nilsson PJ. Omentoplasty in abdominoperineal resection: a review of the literature using a systematic approach. Dis Colon Rectum. 2006
Sep;49(9):1354-61.
www.downstatesurgery.org
MYOCUTANEOUS FLAP RECONSTRUCTION

Advantages:



Disadvantages:





Brings well-vascularized, non-irradiated tissue
Can also allow for functional reconstruction
Increased operative time
Increased cost
Donor site complications
Flap complications
Main options:



Rectus abdominus flap
Gracilis flap
Gluteus maximus flap
Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009 Oct;11(8):806-16.
www.downstatesurgery.org
RECTUS FLAP RECONSTRUCTION





Small cohort study of 19 patients who underwent
rectus flap reconstruction after APR for anorectal
cancer
Compared to control group of 59 patients with
primary closure
Perineal wound complications were seen in 15.8%
and 44.1% (p=0.03)
Incidence of other complications was similar (42.1%
vs 42.4%, p=0.8)
Flap group was generally higher risk (more
vaginectomy, intraop radiotherapy, recurrent disease)
Chessin DB et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study.
Ann Surg Oncol. 2005 Feb;12(2):104-10.
www.downstatesurgery.org
MYOCUTANEOUS FLAP RECONSTRUCTION

Gracilis and Gluteal Flaps:
No controlled clinical trials
 Only restrospective case series and comparative
studies are available
 Most report decreased incidence of perineal wound
complications

No definitive evidence can be given to support
making practice guidelines
 Decision to use a flap is usually based on the
goals of reconstruction

Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009 Oct;11(8):806-16.
www.downstatesurgery.org
SUMMARY
APR is associated with high rate of morbidity
secondary to perineal wound complications
 Primary closure should be performed
 There is evidence to support use of closed
suction drains
 No definitive evidence to support local
antibiotics, omentoplasty, or flap
reconstruction

www.downstatesurgery.org
REFERENCES













Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD. Postoperative complications following surgery for rectal cancer. Ann Surg. 2010
May;251(5):807-18.
Crane CH, Eng C, Feig BW, Das P, Skibber JM, Chang GJ, Wolff RA, Krishnan S, Hamilton S, Janjan NA, Maru DM, Ellis LM, RodriguezBigas MA. Phase II trial of neoadjuvant bevacizumab, capecitabine, and radiotherapy for locally advanced rectal cancer. Int J Radiat
Oncol Biol Phys. 2010 Mar 1;76(3):824-30. Epub 2009 May 21.
Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009 Oct;11(8):80616. Epub 2008 Nov 14. Review.
Nilsson PJ. Omentoplasty in abdominoperineal resection: a review of the literature using a systematic approach. Dis Colon Rectum. 2006
Sep;49(9):1354-61. Review.
Meyer L, Bereuter M, Marusch F, Meyer F, Steinert R, Lippert H, Gastinger I. Perineal wound closure after abdomino-perineal excision of
the rectum. Tech Coloproctol. 2004 Nov;8 Suppl 1:s230-4.
Gruessner U, Clemens M, Pahlplatz PV, Sperling P, Witte J, Rosen HR; Septocoll Study Group. Improvement of perineal wound healing
by local administration of gentamicin-impregnated collagen fleeces after abdominoperineal excision of rectal cancer. Am J Surg. 2001
Nov;182(5):502-9.
Friedman J, Dinh T, Potochny J. Reconstruction of the perineum. Semin Surg Oncol. 2000 Oct-Nov;19(3):282-93. Review.
Irvin TT, Goligher JC. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum.
Br J Surg. 1975 Apr;62(4):287-91.
Robles Campos R, Garcia Ayllon J, Parrila Paricio P, Cifuentes Tebar J, Lujan Mompean JA, Liron Ruiz R, Torralba Martinez JA, Molina
Martinez J. Management of the perineal wound following abdominoperineal resection: prospective study of three methods. Br J Surg.
1992 Jan;79(1):29-31.
Terranova O, Sandei F, Rebuffat C, Maruotti R, Pezzuoli G. Management of the perineal wound after rectal excision for neoplastic
disease: a controlled clinical trial. Dis Colon Rectum. 1979 May-Jun;22(4):228-33.
Fingerhut A, Hay JM, Delalande JP, Paquet JC. Passive vs. closed suction drainage after perineal wound closure following
abdominoperineal rectal excision for carcinoma. A multicenter, controlled trial. The French Association for Surgical Research. Dis Colon
Rectum. 1995 Sep;38(9):926-32.
Hartz RS, Poticha SM, Shields TW. Healing of the perineal wound. Arch Surg. 1980 Apr;115(4):471-4.
Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J, Mehrara B, Minsky BD, Paty P, Weiser M, Wong WD, Guillem JG.
Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg
Oncol. 2005 Feb;12(2):104-10. Epub 2005 Feb 3.