Perineal healing following abdominoperineal excision for rectal and anal cancer

Abstract

Abdominoperineal rectal excision (APE) may be indicated for distal rectal cancer and anal cancer patients. For many patients the extralevator APE (ELAPE) technique in which a larger part of the pelvic floor is removed is commonly used currently. Most patients in whom an APE is performed have received radiotherapy (RT) preoperatively. Perineal healing disorders after APE occur with high frequency and various techniques and measures may be attempted to improve healing rates. Healing disorders create problems for patients and health care systems, but less is known on the possible oncological impact.

Paper I aimed to evaluate perineal healing following ELAPE in patients with perineal reconstruction using a biological mesh. A retrospective single center study of 88 consecutive ELAPE patients between 2011 and 2015 was performed. Three different types of biological mesh were used for perineal reconstruction. 97% of patients had received radiotherapy and 62% had an omentoplasty. Healing rates of 66% and 92% at 3 and 12 months, respectively, were observed. No association was found between examined variables and healing rate at 3 months. Biological mesh for perineal reconstruction following ELAPE is considered feasible and safe.

Paper II aimed to evaluate whether simultaneous perineal reconstruction and parastomal reinforcement with the biological mesh Strattice™ after ELAPE could prevent hernia formation. In a prospective multicenter design, 19 patients were recruited between July 2013 and August 2014. Patients were assessed for perineal and parastomal wound healing on postoperative day 7 and at 1, 3, 6 and 12 months. CT and/or dynamic MRI at one year was used to detect perineal hernia and CT for parastomal hernia. Three parastomal and no perineal hernias were detected. At one year all perineal and parastomal wounds were healed.

The objective of Paper III was to evaluate perineal healing in relation to ERAS compliance, type of resection and method of perineal reconstruction in patients with squamous cell carcinoma of the anus (SCCA) after salvage surgery. Between 2005 and 2015, 101 patients (67 women), in the Stockholm-Gotland region were included. Surgery was performed at two hospitals and ERAS compliance was 71%. 58 patients underwent APE and 43 pelvic exenteration. Perineal reconstruction was by primary closure (39 patients), gluteal myocutaneus flap (31 patients) and vertical rectus abdominis myocutaneou flap (31 patients). Healing at 3 months was achieved in 61 patients and was significantly associated with age and type of perineal reconstruction. At one year, 84 of 89 surviving patients had a healed perineal wound.

In Paper IV, the cohort from Paper III was examined with respect to impact of perineal healing on survival. Following exclusion, 95 patients constituted the study cohort. Healing status at 90 days postoperatively was used as a landmark. R0 was achieved in 93% and overall survival (OS) at 5 years was 61%. In the univariable analysis, an unhealed wound at landmark date was significantly associated with OS and recurrence free survival (RFS) showed a similar relationship (p=0.054, log rank). However, in the multivariable analyses only non-significant trends were indicated.