After Abdominoperineal Resection Research Articles

Propensity-score matched analysis of the pathologic outcomes and survival benefits of neoadjuvant therapy in stage II-III anal adenocarcinoma.

Anal adenocarcinomas are a rare condition which account for less than 10% of anal cancers. The present study aimed to assess the impact of neoadjuvant therapy on the clinical and pathologic outcomes and overall survival (OS) of patients with stage II-III anal adenocarcinomas after abdominoperineal resection (APR). A retrospective cohort study of patients with anal adenocarcinoma in the US National Cancer Database (NCDB) (2010-2020) was conducted. Propensity-score matching was used to compare patients who received neoadjuvant therapy (neoadjuvant therapy group) to the no-neoadjuvant group. The primary outcome was 5-year OS whereas secondary outcomes included conversion to open surgery, hospital stay, surgical margins, 30-day mortality, 90-day mortality, and 30-day readmission. A total of 742 patients (56% male) with a mean age of 63.6 ± 12.4 years were included. A total of 214 patients in the neoadjuvant group were matched with 107 in the no-neoadjuvant group. The mean OS was similar between the two groups (47.5 vs. 44.8 months, p = 0.253). Patients who received neoadjuvant therapy had a longer median time between diagnosis and surgery (151 vs. 54 days, p < 0.001), lower 90-day mortality (1.9% vs. 6.7%, p = 0.046), more pT0 tumors (15.7% vs. 0%), less pT3-4 tumors (28.4% vs. 36.4%, p = 0.001), less pN1-2 tumors (22.9% vs. 34.7%, p < 0.001), and less lymphovascular invasion (16.2% vs. 40%, p < 0.001) than the no-neoadjuvant group. Both groups had similar conversion rates, hospital stay, 30-day mortality, 30-day readmission, and positive surgical margins. Neoadjuvant therapy before APR was associated with significant downstaging of anal adenocarcinomas and lower 90-day mortality, yet similar OS to patients who were surgically treated without neoadjuvant treatment.

OC-097 A THREE LAYERED REPAIR OF A LARGE PERINEAL HERNIA- CASE REPORT AND REVIEW OF THE LITERATURE

Abstract Background A symptomatic perineal hernia is an uncommon complication after abdominoperineal resection (APR). Repairs of such hernias can be achieved by usage of autologous flaps, synthetic mesh or biologic mesh. Studies have shown that prophylactic repair of the pelvic floor with biologic mesh, reduces the incidence of perineal hernia. Data of perineal hernia repair methods are scarce and of poor quality. Aim In this paper we aim to share our experience using a non-conventional technic for the repair of A perineal hernia, as it appears to be a surgical challenge without a clear evidence based recommended technique. Methods A 71-year-old woman, after extended APR with primary closure of pelvic floor with a biosynthetic absorbable mesh, presented to our clinic with a symptomatic, extensive perineal hernia. The patient underwent an open reconstruction of the pelvic floor using a synthetic composite mesh in an underlay intraperitoneal position and a bilateral gluteal muscle flap closure. Results In post-operative-day 11 the patient developed a pelvic fluid collection and surgical site infection. The collection was surgically drained showing clear fluid negative for bacteria and antibiotic treatment was initiated. 3 months after surgery the wound had completely healed and A CT scan showed no recurrence of the hernia. Conclusion Considering the increased incidence of perineal hernia after APR and the superiority of a synthetic mesh in minimizing recurrence rates- a primary closure of the pelvic floor with a synthetic mesh or autologous flap might be justified.

A three layered repair of a large perineal hernia: case report and review of the literature

BackgroundA symptomatic perineal hernia is an uncommon complication after abdominoperineal resection (APR). Repairs of such hernias can be achieved by usage of autologous flaps, synthetic mesh, or biologic mesh, which reduce bowel adhesions. Studies have shown that prophylactic repair of the pelvic floor with biologic mesh during APR, can reduce the incidence of perineal hernia.Case presentationA 71-year-old woman, after extended APR (eAPR) with primary closure of pelvic floor with absorbable mesh, presented to our outpatient clinic with a symptomatic, extensive perineal hernia. The patient underwent repair of the perineal hernia using a synthetic mesh and a bilateral gluteal flap procedure. In post operative care, signs of surgical site infection and a fluid collection demonstrated in a CT-scan, compelled a surgical drainage. A clear fluid negative for bacterial growth was drained and antibiotic treatment was initiated. After drainage, surgical site showed signs of significant improvement and patient was eventually discharged.ConclusionThe rise in reported incidence of perineal hernia after eAPR coupled with the scarcity of data regarding the preferable repair technique suggests that there is a significant need for further prospective comparative studies.

Transanal total mesorectal excision port-assisted perineal hernia repair: A case report

Perineal hernia after abdominoperineal resection (APR) is a troublesome problem, and severe cases require surgical treatment. However, perineal hernia repair is challenging, especially when combined with intestinal adhesions. The difficulty of the operation lies in performing adhesiolysis and mesh placement under poor visibility. While there are traditional, laparoscopic and even robotic methods of performing this procedure, no easy and minimally-invasive approach has been reported. Here, we report the case of a patient with perineal hernia, who underwent transanal total mesorectal excision (TaTME) port-assisted laparoscopic perineal hernia repair. The operation was successful, the postoperative recovery was uneventful, the patient's symptoms improved significantly, and no recurrence was found during the 4-month follow-up. The availability and safety of TaTME port-assisted perineal hernia repair provide a promising approach for hernia repair. Compared with traditional perineal or laparoscopic abdominal approaches, this procedure is less invasive and results in a better field of vision.

Exploring the impact of urogenital organ displacement after abdominoperineal resection on urinary and sexual function

PurposeThis study aimed to establish the functional impact of displacement of urogenital organs after abdominoperineal resection (APR) using validated questionnaires.MethodsPatients who underwent APR for primary or recurrent rectal cancer (2001–2018) with evaluable pre- and postoperative radiological imaging and completed urinary (UDI-6, IIQ-7) and sexual questionnaires (male, IIEF; female, FSFI, FSDS-R) were included from 16 centers. Absolute displacement of the internal urethral orifice, posterior bladder wall, distal end of the prostatic urethra, and cervix were correlated to urogenital function by calculating Spearman’s Rho (ρ). Median function scores were compared between minimal or substantial displacement using median split.ResultsThere were 89 male and 36 female patients included, of whom 45 and 19 were sexually active after surgery. Absolute displacement of the internal urethral orifice and posterior bladder wall was not correlated with UDI-6 in men (ρ = 0.119 and ρ = 0.022) nor in women (ρ = − 0.098 and ρ = − 0.154). In men with minimal and substantial displacement of the internal urethral orifice, median UDI-6 scores were 10 (IQR 0–22) and 17 (IQR 5–21), respectively, with corresponding scores of 25 (IQR 10–46) and 21 (IQR 16–36) in women. Displacement of the cervix and FSDS-R were correlated (ρ = 0.433) in sexually active patients.ConclusionThis first analysis on functional impact of urogenital organ displacement after APR suggests that more displacement of the cervix might be associated with worse sexual function, while the data does not indicate any potential functional impact of bladder displacement. Studies are needed to further explore this underexposed topic.

Case control study investigating the clinical utility of NPWT in the perineal region following abdominoperineal resection for rectal adenocarcinoma: a single center study

BackgroundPerineal wound complications are common after abdominoperineal resection (APR) for rectal adenocarcinoma. Delayed wound healing may postpone postoperative adjuvant therapy and, therefore, lead to a worse survival rate. Negative-pressure wound therapy (NPWT) has been suggested to improve healing, but research on this subject is limited.MethodsThe aim of this study was to assess whether NPWT reduces surgical site infections (SSI) after APR for rectal adenocarcinoma when the closure is performed with a biological mesh and a local flap. A total of 21 consecutive patients had an NPWT device (Avelle, Convatec™) applied to the perineal wound. The study patients were compared to a historical cohort in a case–control setting in relation to age, body mass index, tumor stage, and length of neoadjuvant radiotherapy. The primary outcome was the surgical site infection rate. The secondary outcomes were the wound complication rate, the severity of wound complications measured by the Clavien–Dindo classification, length of hospital stay, and surgical revision rate.ResultsThe SSI rate was 33% (7/21) in the NPWT group and 48% (10/21) in the control group, p = 0.55. The overall wound complication rate was 62% (13/21) in NPWT patients and 67% (14/21) in the control group, p > 0.90. The length of hospital stay was 15 days in the NPWT group and 13 in the control group, p = 0.34. The wound severity according to the Clavien–Dindo classification was 3b in 29% (6/21) of the NPWT group and in 38% (8/21) of the control group. A surgical revision had to be performed in 29% (6/21) of the cases in the NPWT group and 38% (8/21) in the control group, p = 0.73.ConclusionNPWT did not statistically decrease surgical site infections or reduce wound complication severity in perineal wounds after APR in this case–control study. The results may be explained by technical difficulties in applying NPWT in the perineum, especially in female patients. NPWT devices should be further developed to suit the perineal anatomy before their full effect can be assessed.Trial registration The study was registered as a prospective registry study (266/2018, registered 15th of November 2018)

Mesh, flap or combined repair of perineal hernia after abdominoperineal resection - A systematic review and meta-analysis.

The aim of this systematic review was to analyse recurrence rates after different surgical techniques for perineal hernia repair. All original studies (n ≥ 2 patients) reporting recurrence rates after perineal hernia repair after abdominoperineal resection (APR) were included. The electronic database PubMed was last searched in December 2021. The primary outcome was recurrent perineal hernia. A weighted average of the logit proportions was determined by the use of the generic inverse variance method and random effects model. A total of 19 studies involving 172 patients were included. The mean age of patients was 64 ± 5.6 years and the indication for APR was predominantly cancer (99%, 170/172). The pooled percentage of recurrent perineal hernia was 39% (95% CI: 27%-52%) after biological mesh closure, 29% (95% CI: 21%-39%) after synthetic mesh closure, 37% (95% CI: 14%-67%) after tissue flap reconstruction only and 9% (95% CI: 1%-45%) after tissue flap reconstruction combined with mesh. Recurrence rates after mesh repair of perineal hernia are high, without a clear difference between biological and synthetic meshes. The addition of a tissue flap to mesh repair seemed to have a favourable outcome, which warrants further investigation.

Perineal hernia repair after abdominoperineal resection (APR) with the laparoscopic-peritoneal dual fixation technique.

Perineal hernia (PH) following abdominoperineal resection (APR) is a rare but challenging problem. Although different techniques have been described in literature, the recurrence rate is still remarkable, and there is no consensus regarding the optimal repair approach. In the present study, we reported our experience based on a consecutive series of ten cases. Ten symptomatic large perineal hernias were repaired exclusively with the same laparoscopic-perineal dual fixation technique. Key steps consist laparoscopic adhesiolysis, hernia contents reduction, open excess perineal hernia sac resection, and mesh placement and dual fixation. Frist, a coated mesh was fixed to the sacrum and pelvic sidewalls with the metallic tacks in the laparoscopic step, second, the mesh was fixed anteriorly to urogenital diaphragm and laterally to the sacrotuberous ligament with permanent sutures in the perineal step. Ten symptomatic PHs were repaired by the same laparoscopic-perineal dual fixation technique, 6 males and 4 females, median age at the time of repair was 69.5years (range 66-77years), the BMI was 24 ± 1. Four concomitant procedures were performed, including bilateral inguinal hernia repair with the transabdominal preperitoneal repair (TAPP) in one case, and laparoscopic parastomal hernia repair in two patients. The average operative time was 171 ± 45min; the postoperative average hospital stay was 14 ± 4days. There was no perineal hernia recurrence during the follow-up period (the median follow-up was 42months; range 1-63months). Perineal hernia after APR is a rare and challenging postoperative complication, although many different approaches have been described, the recurrence is still high and the best method cannot be drawn. The present laparoscopic-perineal dual fixation approach proved to be a reproducible, effective and durable technique, and gave excellent results during the medium-long-term follow-up.

Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study.

Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment. Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model. A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3). Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.

Perineal Hernia another Complication That Influences the Quality of Life after Amputation of the Rectum: Case Report

Introduction: Perineal eventration or perineal hernia is a protrusion of the pelvic floor containing intra-abdominal viscera. The occurrence of postoperative perineal hernia after abdominoperineal resection (APR) is rare, but has increased recently affecting the quality of life of the patient. Presentation of case: Here, we report a 68 -year-old women with history of myomectomy was diagnosed with a low rectal cancer. She has abdominoperineale resection after radiotherapy. She was operated for white line hernia 2 years after with mesh fixation. She presented to us 5 months after the operation, with perineal bulge and discomfort. The diagnosis of a perineal hernia was made clinically and was complemented by a CT scan. Abdominal CT scan showed that part of the small intestine was slightly protruding from a large defect of the pelvis. Discussion: Recurrence rates of perineal eventration has increased recently. Many approaches have been described, but there is still no consensus as to the optimal repair technique for perineal eventration. Conclusion: This case report confirm that perineal eventration is frequent in women such as literature with other risk factors like APR radiotherapy and a history of pelvic surgery.

Quantifying displacement of urogenital organs after abdominoperineal resection for rectal cancer.

AimThis study aimed to quantify displacement of urogenital organs after abdominoperineal resection (APR), and to explore patient and treatment characteristics associated with displacement.MethodPatients from 16 centres who underwent APR for primary or recurrent rectal cancer (2001–2018) with evaluable preoperative and 6–18 months postoperative radiological imaging were included in the study. Anatomical landmarks on sagittal images were related to a coordinate system based on reference lines between fixed bony structures and absolute displacements were calculated using the Pythagorean theorem. Rotation of landmarks was measured relative to a pubic‐S5 reference line.ResultsThere were 248 patients included of which 171 were men and 77 women. The median displacement of the internal urethral orifice was 25 mm in men (maximum 65), and 17 mm in women (maximum 50). Rotation of the internal urethral orifice was in a caudal direction in 160/170 (94%) of men and 65/73 (89%) of women, with a median of 32 degrees (maximum 85) and 33 degrees (maximum 83), respectively. Displacements of the posterior bladder wall, distal end of prostatic urethra and cervix were significantly correlated with the internal urethral orifice. In linear regression analysis, biological mesh reconstruction of the pelvic floor and visceral interposition were significantly associated with increased displacement of the internal urethral orifice, and female gender and any filling of the presacral space with decreased displacement.ConclusionsSubstantial absolute displacement and rotation of urogenital organs after APR for rectal cancer were observed, but with high variability among both men and women, and being significantly associated with reconstructive interventions.

Usefulness of Omentoplasty to Reduce Perineal Wound Complications in Abdominoperineal Resection After Neoadjuvant Chemoradiotherapy

Omentoplasty is sometimes used to prevent perineal wound complications after abdominoperineal resection (APR) following neoadjuvant chemoradiotherapy (NACRT). However, recent studies have raised some controversy about its clinical benefit. Outcomes for rectal cancer patients who received APR after NACRT were retrospectively compared between the groups with omentoplasty (n=28) and without omentoplasty (n=14). The operative time was significantly longer in the omentoplasty group (575 vs. 404 min, p<0.001). Laparoscopic surgery was performed more frequently in the omentoplasty group. Perineal wound problems including dehiscence and infection were significantly reduced in the omentoplasty group (46.4% vs. 78.6%, p<0.001). Univariate and multivariate analyses revealed that omentoplasty was the most important factor in reducing perineal wound complications (odds ratio=0.020, 95% confidence intervaI=0.001-0.393; p=0.001). Omentoplasty was useful in reducing perineal wound complications after APR following NACRT.

The impact of laparoscopic technique on the rate of perineal hernia after abdominoperineal resection of the rectum.

To determine the impact of surgical technique on the incidence of perineal hernia after abdominoperineal resection (APR). A retrospective analysis was performed on patients who underwent APR between May 2007 and March 2018 at our institution using our prospectively maintained Colorectal Cancer Database. Demographic and clinical parameters were compared between the open APR (OAPR) and laparoscopic APR (LAPR) groups using Student's t test, chi-squared, or Fisher's exact test. Putative risk factors were then analyzed using a Cox proportional hazard model with perineal hernia as the outcome. The study included 261 patients (191 OAPR and 70 LAPR). Intraoperative blood loss (596.0 ± 633.4 vs. 307.0 ± 307.2mL, p < 0.001), duration of OR (249.6 ± 115.6 vs. 212.6 ± 75.1min, p = 0.004), and length of stay (15.6 ± 18.0 vs. 10.4 ± 12.6days, p = 0.031) were all greater for OAPR than LAPR patients, but wound complications other than hernia did not differ significantly. Perineal hernia was observed in 2.1% of OAPR and 12.9% of LAPR patients. In multivariable analysis, significant risk factors for perineal hernia were age, laparoscopic technique, and closure of the perineal wound with myocutaneous flap (HR 1.08, 11.13, and 31.51, respectively, all p < 0.05). LAPR, although associated with less blood loss and shorter length of hospital stay than OAPR, was a significant risk factor for perineal hernia.

Gender aspects of survival after abdominoperineal resection for low rectal cancer: a retrospective study.

The difference in prognosis between genders after abdominoperineal resection (APR) for low rectal cancer (LRC) is unclear. This study aimed to compare survival outcomes between genders in patients with LRC who underwent curative APR. This retrospective cohort study used a database of consecutive colorectal resections. Patients who received curative APR with LRC were grouped according to their gender. Female patients were frequency-matched 1:1 on American Joint Committee on Cancer (AJCC) stage to male patients. Overall survival (OS), disease-free survival (DFS), and their independent risk factors were examined. A total of 140 patients with APR for LRC were included after matching: 70 (50.0%) males and 70 (50.0%) females. No significant differences were found between the groups in terms of age, operation methods, AJCC stage, and adjuvant therapy (all P > 0.05). Median follow-up was 39 (range: 3-128) months. Male gender was independently associated with worse OS (adjusted hazard ratio [HR] = 2.755, 95% CI: 1.507-5.038, P = 0.001) and worse DFS (adjusted HR = 2.440, 95% CI: 1.254-4.746, P = 0.009). Subgroup analysis revealed that female patients with stage III disease had better OS (P = 0.001) and DFS (P < 0.001) than male patients. Gender affects survival after a curative APR for LRC. Compared with females, male patients with LRC after curative APR had worse prognosis, especially for stage III disease.

CT assessment of the quality of omentoplasty and its implications for perineal wound healing

PurposeThis study was designed to examine the impact of an omentoplasty and its quality on pelviperineal morbidity after abdominoperineal resection (APR) for rectal cancer.MethodsThis was a retrospective single-centre study of consecutive patients undergoing APR for primary or recurrent rectal cancer between 2000 and 2018. Quality of omentoplasty was categorised (sufficient vs insufficient) based on postoperative CT scans. Main study endpoints were perineal wound healing and perineal hernia.ResultsThis study included 100 patients: 16 with a sufficient omentoplasty, 16 with an insufficient omentoplasty, and 68 without omentoplasty. Rate of pelviperineal complications within 30 days was 44%, 69% and 64% (P = 0.283), and delayed wound healing at 3 months was 19%, 54% and 27%, respectively (P = 0.109). Sufficient omentoplasty was not significantly associated with less delayed healing in multivariable analysis (OR 0.597; 95% CI 0.149–2.397). An insufficient omentoplasty demonstrated significantly higher rates of delayed healing at 6 months (46% vs 14%; P = 0.016) and chronic perineal sinus at 12 months (31% vs 3%; P = 0.008) compared with no omentoplasty.ConclusionThis relatively small series suggest that even a sufficient omentoplasty, as determined by postoperative imaging, does not reduce pelviperineal morbidity after APR for rectal cancer. The methodology of CT-based assessment of an omentoplasty as well as the correlation with postoperative outcomes has to be validated in future studies.

Laparoscopic extraperitoneal sigmoid colostomy using the totally extraperitoneal hernia repair technique after abdominoperineal resection for rectal cancer.

Stoma creation through the extraperitoneal route reportedly reduces the risk of parastomal hernia and stomal prolapse after abdominoperineal resection (APR) for rectal cancer. We describe a new technique for laparoscopic extraperitoneal sigmoid colostomy following APR. After the rectus abdominis muscle is separated, Lap ProtectorTM and EZ AccessTM devices are placed. An extraperitoneal stoma tunnel is created laparoscopically as much as possible. Next, the peritoneum is separated from the inside of the abdominal cavity, and the extraperitoneal tunnel is opened. At the time of writing, we had performed laparoscopic extraperitoneal sigmoid colostomy in eight patients, without any complications or conversion to the conventional procedure. Thus, laparoscopic extraperitoneal sigmoid colostomy is a useful and safe technique for the laparoscopic creation of an extraperitoneal stoma tunnel after APR.

Establishment of a nomogram predicting risk factors of postoperative perineal wound complications after abdominoperineal resection for rectal cancer

Objective: To investigate the risk factors of perineal incision complications after abdominoperineal resection (APR) for rectal cancer, and to establish a nomogram model to predict the complications of perineal incision. Methods: A case-control study was conducted to retrospectively collect the medical records of 213 patients with colorectal cancer who underwent APR at the First Affiliated Hospital of Nanjing Medical University from January 2010 to December 2016. The complications of perineal incision after APR were classified according to the modified Clavien-Dindo classification of surgical complications (Version 2019), and the complications of grade II and above were defined as "clinically significant complications" .Twenty-two factors related to complication of perineal incision, such as gender, age, surgical procedure, surgical approach, perineal repair, placement of drainage tube, skin position of drainage tube, operation time, intraoperative blood loss, preoperative radiotherapy and chemotherapy, intraoperative local perfusion chemotherapy, tumor classification, pathological grade, tumor T stage, tumor TNM stage and so on, were analyzed by chi-square test for univariate risk factor of complication in all variables, and variables with P<0.2 in univariate analysis were further included in multivariate analysis. Logistic regression analysis was used to screen out independent risk factors. R software (R 3.3.2) was introduced. The rms software package was used to construct a nomogram prediction model. The C-index was calculated (higher meaning better consistency with actual risk) to evaluate the discriminant degree of the model. The Bootstrap method was used to repeat the sampling for internal verification. A total of 42 patients with colorectal cancer who underwent APR from January 2017 to December 2017 at the First Affiliated Hospital of Nanjing Medical University were externally validated, and the corrected C-index was calculated. The model conformity was determined by comparing the C-index calibration difference between the predicted and actual risks. Results: Of the 213 patients with colorectal cancer, 131 were male and 82 were female, with mean age of (59.6±11.6) years. The incidence of postoperative perineal incision complications was 20.2% (43/213), including 27 cases of Clavien-Dindo II and above complications. Univariate analysis showed that the Eastern Cancer Cooperative Group (ECOG) score, preoperative albumin, skin position of drainage tube, intraoperative blood loss, preoperative radiotherapy and chemotherapy were associated with complications of postoperative perineal incision (All P<0.05) . Multivariate analysis showed that preoperative albumin levels ≤38 g/L (OR=105.261, 95% CI: 7.781 to 1423.998, P<0.001), perinead drainage (OR=11.493, 95% CI: 1.379 to 95.767, P=0.024), intraoperative blood loss >110 ml (OR=6.476, 95% CI: 1.505 to 27.863, P=0.012) and preoperative radiotherapy and chemotherapy (OR=7.479, 95% CI: 1.887 to 29.640, P=0.004) were postoperative clinically significant independent risk factors for perineal incision complications. The nomogram model was established. Preoperative albumin level <38 g/L was for 100 points, the preoperative chemoradiotherapy was for 52.5 points, the intraoperative blood loss >110 ml was for 28.5 points, and the perineal drainage was for 17.5 points. Adding all the points was the total score, and the complication rate corresponding to the total score was the predicted rate of the model. The model had a C-index of 0.863. After internal verification, the C-index dropped by 0.005. External verification showed a C-index of 0.841. Conclusions: Preoperative nutritional status, skin position of drainage tube, intraoperative blood loss and preoperative radiotherapy and chemotherapy may affect the occurrence of perineal wound complications after APR for rectal cancer. The nomogram model constructed in this study is helpful for predicting the probability of clinically significant complications after APR.

Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis.

Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease. We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure. Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes. This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.

A Case of Sigmoid Colon Ischemic Colitis of the Necrotizing Type Occurring After Abdominoperineal Resection (APR) Via the Retroperitoneal Route

A Case of Sigmoid Colon Ischemic Colitis of the Necrotizing Type Occurring After Abdominoperineal Resection (APR) Via the Retroperitoneal Route

Magnetic resonance imaging features of persistent perineal sinus

Objective To summarize the magnetic resonance imaging (MRI) features of the persistent perineal sinus (PPS). Methods The retrospective and descriptive study was conducted. The clinical data of 7 patients with PPS who were admitted to the Nanjing University of Traditional Chinese Medicine between July 2010 and January 2017 were collected. Patients received horizontal, anteroposterior axes and coronal scanning of MRI after abdominoperineal resection (APR) of rectal cancer. Two physicians read collectively films and then achieved consistent results if there was a disputed result. Observation indicators: (1) MRI features; (2) treatment and follow-up situations. Patients underwent resection of PPS according to results of MRI examination, and then regular pathological examination. Follow-up using telephone interview was performed to detect sinus recurrence and reoperation up to April 2017. Results (1) MRI features: ① Lesion location: lesions of PPS in 7 patients were located at the presacral areas, top side was up to the third sacral plane, and lower side extended down to the pubic area. ② Morphology and signal: sinus tract of 7 patients showed irregular flaky and tubular abnormal signals; fibrotic sinus tract wall showed low signals in T1 weighted imaging (T1WI) and T2WI; contents of sinus tract in 7 patients showed low signal in T1WI and high signals in T2WI and T2WI-fat suppression (T2WI-FS). Of 7 patients, uniform signal and mixed signal were respectively detected in 2 and 5 patients. ③ Branches and cystic spaces: 1 patient had a branch at the tip of the coccyx, extending to the rear of the sacral vertebra. The top of sinus tract in 4 patients enlarged to form a cavity. ④ Signs of infection: signs of infection in 3 patients included blurred and exuded fat gaps around the sinus tract, unclear and partially adhesion with pelvic organ; the pelvic floor muscles in 1 patient were thickened and swollen, with a high signal in T2WI-FS; flaky fluid shadows in 2 patients were seen in the posterior sinus, with a high signal in T2WI-FS, showing a tissue edema of anterior sacrum. ⑤ Enhancement features: result of MRI examination of 1 patient showed mild and heterogeneous enhancement of sinus. (2) Treatment and follow-up situations: among 7 patients undergoing sinus resection, 2 received curettage of superior sinus due to high location, and 5 received successfully operation. All patients underwent postoperatively regular antibiotic therapy. The healing time was 14-78 days, with an average time of 42 days. The postoperative pathological examination showed different degrees of inflammatory cell infiltration. Seven patients were followed up for 2-74 months, with an average time of 40 months. Of 7 patients, sinus in 6 patients was healed, 1 had recurrence of sinus and didn′t receive therapy. Seven patients didn′t undergo debridement or transposition of skin flap again. Conclusion The MRI imaging features of PPS includes flaky and tubular abnormal signal in the the anterior sacrum, low signal in T1WI, high signals in T2WI and T2WI-FS, and the enhanced scanning of sinus duct shows mild and heterogeneous enhancement. Key words: Persistent perineal sinus; Magnetic resonance imaging; Imaging examination; Sinus resection