Options for pelvic floor reconstruction after extralevator abdomin-operineal resection (APR): Myocutaneous flap or porcine dermal collagen implant

Abstract

S 979 procedure can be considered palliative in the majority of recurrences. Based on equal cancer treatment, the reduction of surgical trauma and preservation of anatomical integrity are an important result. Options for pelvic floor reconstruction after extralevator abdominoperineal resection (APR): Myocutaneous flap or porcine dermal collagen implant E. Cardone****, D. Rega*, D. Scala*, P. Tammaro*, C. Sassaroli*, S. Mori**, L. Montesarchio*, U. Pace*, P. Delrio* *Department of Colorectal Surgical Oncology, I.N.T. “G.Pascale” Foundation, Naples, Italy **Department of Soft Tissues and Melanoma Surgical Oncology, I.N.T. “G.Pascale” Foundation, Naples, Italy * Corresponding author: Eleonora Cardone, via I trav.casilli 4 cap 80144Napoli, Italy. Cell: +39 3384983621; fax: +39 0817541967. E-mail address: criceto81@live.it (E. Cardone). Background: Reconstruction of the pelvic floor after extralevator abdominoperineal resection (APR) for advanced low rectal cancer is a challenge for the colorectal surgeon. Different approaches have been described. Methods: We report our approaches to reconstruction using the modified vertical rectoabdominal myocutaneous (VRAM) flap and porcine dermal collagen implant (Permacol) in 8 patients, evaluating the drawbacks and advantages. All patients were operated on for advanced low rectal cancer treated by neoadjuvant chemoradiation; 4 patients underwent reconstruction with a modified VRAM flap and 4 with perineal insertion of a Permacol implant. The modified VRAM flap is a myocutaneous portion of the rectum of the abdomen with its posterior fascia, re-allocated at the perineal wound. The Permacol implant is sutured to the lateral cut edges of the levator ani, anteriorly to the vagina fascia (or prostatic fascia) and posteriorly to both sides of the coccyx. Results: Reconstruction with the modified VRAM flap was 90 minutes longer than with the Permacol implant. A plastic surgeon was required. Postoperative mobilization after the VRAM flap procedure was allowed at day 3 and at day 2 after reconstruction with the Permacol implant. Postoperative pain was lower in the patients who had received a VRAM flap presumably because of the absence of perineal sutures. Slight dehiscence of the VRAM flap occurred in 1 patient. Perineal seroma developed in 3 patients who had received a Permacol graft, and 1 patient developed a perineal abscess. No patients developed abdominal or perineal hernia in a mean follow-up time of 10 months. Conclusions: Both the modified VRAM flap and the Permacol graft are valid approaches in the reconstruction of perineal wounds after extralevator APR. A myocutaneos flap might offer better long-term results but it requires a more complex and longer operation. A biological implant might be considered for patients with previous abdominal scars and poor shortterm prognosis. Improving surgical technique in colorectal surgery: Complete mesocolic excision A. Cassiano*, T. Zurleni**, E. Gjoni*, A. Ballabio*, R. Casieri*, L. Armiraglio*, F. Zurleni* *Department of General Surgery, A.O. Circolo di Busto Arsizio, P.O. di Busto Arsizio, Italy * Corrisponding author: Tommaso Zurleni, Dipartimento di Chirurgia Generale Ospedla di Busto Arsizio (VA), Italy. Tel.: +0331/699 578 716; fax: 0331/699578. E-mail address: tzurleni@yahoo.it (T. Zurleni). Background: Advances in rectal surgery over the past 15 years have been gained with surgical techniques such as total mesocolic excision (TME). Hohenberger described a comprehensive method called complete mesocolic excision (CME) which involves complete excision of all mesocolic tissue and should be performed for any colectomy. Here we describe the difference between the traditional surgical method and CME, and provide data on the technique, morbidity, mortality and lymph node status in the CME procedure. Methods: From January 2009 to December 2011, 110 patients with tumors located from the caecum to the traverse colon were included in the study. The CME technique entails excision of all mesocolic tissue until the origin of the ileocolic artery, right colic artery, and medial colic artery for tumors of transverse colon; the Kocher maneuver is usually performed. The gastroepiplooic vessels are ligated at the origin and the gastrocolic ligament is excised from the greater gastric curvature. Surgery was performed using the CME method with central vascular excision in 77 cases. The control group was 33 cases with tumors located in the same sites for which surgery was performed with a traditional procedure. Results: Significantly more lymph nodes were retrieved in the CME group (35.07 13.96) than those in the control group (25.97 11.27) (P 0.05). There were no differences in hospital stay and postoperative complications between the two groups (P >0.05). No anastomotic leaks or deaths were recorded. The intraoperative operating time in the CME group was longer (CME 177 min vs. controls 150 min; P 11.7 ng/mL (P1⁄40.005). The preoperative cfDNAwas significantly higher in patients with recurrence after surgery than in those without recurrence: 75.1+105.4 ng/mL vs. 33.0+57.8 ng/mL; P1⁄40.019. A progressive increase in cfDNA values