Vertical Rectus Abdominis Musculocutaneous Flap Repair Improves Perineal Wound Healing after Abdominoperineal Resection for Irradiated Locally Advanced Rectal Cancer

Abstract

Radiotherapy (RT) and subsequent abdominoperineal resection (APR) for locally advanced rectal cancer (LARC) is associated with significant perineal wound morbidity. The aim of the present study was to investigate if vertical rectus abdominis musculocutaneous (VRAM) flap repair after APR in LARC patients improves perineal wound healing compared with direct perineal wound closure (non-VRAM). LARC patients (n=329) operated with APR between January 2006 and December 2015 after neoadjuvant RT of ≥25Gy were identified, including 260 and 69 patients in the non-VRAM and VRAM groups, respectively. Perineal wound healing was assessed 3months postoperatively, and risk factors for perineal wound complications and associations with short- and long-term outcome were analyzed. Delayed perineal wound healing after 3months was more frequent in the non-VRAM group (31.5%) compared with the VRAM group (10.4%) (p<0.01). In the non-VRAM group, 26.9% of patients developed pelvic abscess, compared with 10.1% in the VRAM group (p<0.01). Significant risk factors for perineal wound morbidity were non-VRAM (odds ratio [OR] 3.94, 95% confidence interval [CI] 1.72-9.00; p=0.02), positive circumferential resection margin (R1; OR 3.64, 95% CI 1.91-6.93; p<0.01), pelvic abscess (OR 3.27, 95% CI 1.90-5.63; p<0.01), and short-course RT (OR 3.81, 95% CI 1.75-8.30; p<0.01). Perineal wound morbidity was not associated with impaired long-term oncologic outcome. VRAM flap reconstruction of the perineum is associated with an increased wound healing rate and may protect against pelvic abscess development. However, procedure-related long-term morbidity is incompletely studied and the procedure should be reserved for selected patients.