Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision

Abstract

Perineal wound complications after abdominoperineal excision (APE) for anorectal cancer represent a considerable source of morbidity for patients. Strategies to improve wound healing include reconstruction with myocutaneous flaps. This is an evidence-based review of reconstruction of pelvic defects after APE, using rectus abdominus (RAM), gracilis and gluteus maximus flaps. A Pubmed search was performed using MESH headings. Thirty-six studies reported outcomes of interest. Five controlled studies reported improved outcomes after APE and chemoradiotherapy with RAM reconstruction and two controlled studies reported improved outcomes with gracilis reconstruction. There were seven patients with total flap loss after RAM reconstruction, in a combined 300 patients. There were eight patients with complete cutaneous necrosis after gracilis reconstruction in a combined 83 patients. Data from the controlled studies support the use of myocutaneous flaps for single-stage reconstruction after APE in the presence of chemoradiotherapy. Ultimately, the choice of flap depends on the goals of reconstruction, size of the defect and the availability of donor tissue. The implications of an expanding role for radiotherapy in the treatment of low rectal cancer and radical dissection to achieve negative circumferential margins, necessitate close co-operation between colorectal and reconstructive surgeons to achieve APE with reduced wound morbidity.