Unhealed Perineal Wound Research Articles

Displacement of dermal-subcutaneous flaps to close an unhealed wound after abdominoperineal rectal amputation – a case report

Healing of a perineal wound is a very important step in the treatment process after abdominoperineal amputation for rectal cancer. An unhealed wound is a significant clinical problem as it delays the implementation of adjuvant therapy and can become a source of generalised infection. Treatment options include surgical wound debridement and negative pressure therapy, as well as musculocutaneous flap grafting and an inverted gluteal flap techniques. Despite the development of modern therapeutic approaches, difficult-to-heal wounds remain a significant clinical challenge. Some techniques may be ineffective or unfeasible in selected cases. We then go back to traditional surgical techniques. The paper presents a case of treating an unhealed perineal wound by gluteal dermal-subcutaneous flap displacement. In this case, an excellent cosmetic and functional outcome was achieved 30 days after the repair. Traditional surgical techniques, such as the dermal-subcutaneous flap displacement described in this article, are still applicable in the treatment of hard-to-heal wounds after abdominoperineal rectal amputation.

Management of Nonhealing Perineal Wounds

The manifestations of perianal Crohn's disease vary from primary lesions such as skin tags and fissures, to diffuse septic destruction of tissue and sphincter muscle. These manifestations are often persistent and refractory to surgical treatment; however, a more disappointing scenario is when the treatment itself results in a chronic wound. The ideal approach for management involves basic surgical principles, careful patient selection, and realistic expectations. Choice of appropriate procedure, effective elimination of sepsis, thorough evaluation to rule out concomitant systemic disease, and appropriate use of fecal diversion are each an important principle. If proctectomy is necessary, several strategies such as intersphincteric dissection, avoidance of fecal contamination, and appropriate wound closure, are effective in diminishing the postoperative morbidity of an unhealed perineal wound. When an unhealed perineal wound develops in a patient with Crohn's disease, the initial management is conservative. When surgical treatment is necessary, success depends on careful patient selection, optimizing the patient's condition, elimination of sepsis, and choice of an effective technique for healing.

Results of surgical removal of the pouch after failed restorative proctocolectomy.

Restorative proctocolectomy is the elective surgical procedure of choice for ulcerative colitis and familial adenomatous polyposis. Most patients have a satisfactory outcome, but at ten years 15 percent or more will have failed, needing indefinite defunctioning or excision of the pouch. There is little information on the morbidity of pouch excision. The study was designed to present the early results of surgical removal of the pouch after failed restorative proctocolectomy with reference to the indications and intermediate complications, particularly of the perineal wound. Between 1977 and 2002, 996 patients underwent a restorative proctocolectomy at our hospital and 245 patients were referred for potential salvage. The pouch was excised in 58 and 10 patients respectively. There were 40 females and 28 males (median age, 34 (14-65) years) including 47 with ulcerative colitis, 10 with Crohn's disease, and 11 with familial adenomatous polyposis. The median follow-up was 79 (range, 3-312) months from excision. There was one (1.4 percent) postoperative death. The overall morbidity rate was 62.3 percent (immediate 30 days (25 percent), late (53.7 percent)). Thirty-six patients (53.7 percent) were readmitted on 67 occasions for a late complication. The risk of readmission from the time of pouch excision was 38 and 58 percent at one and five years, respectively. Surgical treatment was required during 48 of these readmissions. A persistent perineal sinus was the most common late complication. The perineal wound was not healed at 6 months in 27 patients (40 percent) and at 12 months in 7 patients (10 percent). No factor, including age at the time of pouch excision, gender, indication for excision, or final histologic diagnosis, was associated with an unhealed perineal wound. Two males (7 percent) had impotence. One female suffered from short-bowel syndrome with the need of permanent parenteral nutrition. The median overall hospital stay for all admissions was 20 (range, 8-220) days. Pouch excision is associated with high morbidity. Perineal wound-delayed healing is the commonest late complication and often requires further surgery.

Perianal Crohn's disease--is it all bad news?

The outcome of treatment of perianal Crohn's disease was assessed in 127 patients. A retrospective review of the case notes of 415 patients who were seen in the North East of Scotland between 1985 and 1989 was undertaken. A total of 127 of 415 patients with Crohn's disease had perianal involvement. In 56 patients, perianal disease was the presenting complaint. Ninety-nine of the 127 patients had colonic involvement. Thirty-two were treated with metronidazole and 41 were treated with azathioprine, with at least temporary improvement in 91 and 68 percent, respectively. Seventy patients had treatment for fistula-in-ano, and in 50 percent of patients permanent healing was achieved. In general, treatment and outcome were largely related to the extent and severity of gut involvement. Proctectomy was performed in 32 patients (in 11 because of ongoing colonic disease). Only seven patients had proctectomy solely because of perianal disease. Proctectomy was necessary in 32 of 99 patients with colitis and perianal disease but in none of 28 patients without colonic involvement. Primary healing of the perineal wound was obtained in 17 patients, and only one patient has an unhealed perineal wound at the time of reporting. Perianal Crohn's disease does not inevitably lead to panproctocolectomy. Cautious surgery for fistula when rectal inflammation is quiescent is worthwhile. Loss of bowel continuity is more likely when colitis coexists with perianal disease. Panproctocolectomy is often indicated because of the combination of colitis and perianal disease rather than for perianal disease alone.

Low Hartmann's procedure for severe anorectal Crohn's disease.

Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and perineal fistulas, necessitating excisional surgery, underwent a low Hartmann's procedure in lieu of a standard proctectomy. Fifteen of the 25 (60 percent) patients had a completely healed perineum and required no further surgical therapy. Although perineal disease persisted in the other 10 patients, their perinea were much improved compared with the initial presentation. Following a low Hartmann's procedure, the rectal stump becomes atrophic and anoperineal disease regresses, thereby permitting subsequent perineal proctectomy in less inflamed tissues. Since only a 3-cm to 5-cm cuff of rectum was retained from the initial surgery, a perineal intersphincteric approach could be employed and no abdominal dissection was necessary. Of the 10 patients who subsequently underwent perineal proctectomies, three patients still have an unhealed perineum. Twenty-two of the 25 (88 percent) patients have a completely healed perineum (mean follow-up period, 69.1 months). No attempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the problem of the unhealed perineal wound can be averted with this approach, thereby reducing the long-term morbidity to the patient.

Improved Management of the Perineal Wound after Prootectomy

In an effort to avoid the failures of perineal wound healing that are common after proctectomy, 57 patients who had abdominoperineal resection of the rectum or total proctocolectomy for ulcerative colitis (35 patients), Crohn's colitis (12), or carcinoma (10) had primary closure of the levator muscles and perineal tissues. No attempt was made to approximate the pelvic peritoneum. The small bowel was allowed to fill the pelvic space, which was also drained by suction catheters brought out through the lower abdominal wall. The skin and subcutaneous tissues were allowed to heal by secondary intention in seven patients who had excessive preoperative perineal sepsis from fistulas, deep fissures, and abscesses. All seven wounds healed within 2 months. Of the other 50 patients, whose wounds were closed to the skin, 48 were discharged with completely healed perineal wounds. Two patients had sterile pelvic hematomas that drained through the perineum and delayed wound healing 1 month and 2 months. There were no postoperative perineal, pelvic, or intraabdominal abscesses. Immediate postoperative ambulation was allowed. There was no increased short-term or long-term incidence of small bowel obstruction related to this procedure, nor did perineal hernia occur after long-term observation (mean: 5.3 years). This method of accomplishing perineal wound healing is simpler, safer, more comfortable, and remarkably effective in eliminating the prolonged morbidity of an unhealed perineal wound. It is superior to any other reported method of managing the perineal wound in patients with inflammatory bowel disease and may be applicable to the treatment of cancer without compromising the chances for cure.

Unhealed perineal wound: Lavage with a pulsating water jet

The use of the pulsating water jet lavage (Water Pik) in the care of the perineal wound is discussed. The relative ease with which debridement of a difficult-to-locate perineal wound can be efficiently debrided and cared for by a patient on an ambulatory basis is stressed. This facilitates early patient hospital discharge and offers effective self-care to the patient.

Primary perineal closure after proctocolectomy for inflammatory bowel disease: Prevention of the persistent perineal sinus

In seventeen patients who had a proctocolectomy for ulcerative or granulomatous colitis, the levator muscles and perineal tissues were sutured primarily. In all patients the pelvic peritoneum was left open to allow the remaining intestine to fill the pelvic space. In eight patients in whom the pelvic space was not drained, uncomplicated healing occurred in five, but the other three patients developed infected pelvic collections leading to delayed perineal wound healing. In the subsequent nine patients in whom the pelvic space was drained, all patients had uncomplicated healing. There has been no instance of perineal hernia or intestinal obstruction during four years' observation. This method of managing the pelvic space and perineal wound, based upon obviating all blood or serum collections, has been simple, safe, comfortable, and effective in eliminating the prolonged morbidity of an unhealed perineal wound.

Grafting the Unhealed Perineal Wound After Coloproctectomy for Crohn Disease

The unhealed perineal wound following proctectomy for Crohn disease is a most unfortunate and disabling complication; treatment has been generally unsuccessful and disappointing. Since 1967, we have managed these wounds by skin-grafting the raw surface of the saucerized wound, rather than by attempting to obliterate the cavity. The graft is applied to the defect two or three days after wide debridement and saucerization. No attempt is made to cover more than the readily accessible raw surface. The graft is first dressed on the third postoperative day, and daily thereafter. The patient receives 40 units of corticotropin (ACTH) daily during his hospital stay; the drug therapy is continued in smaller dosage for several months. Results to date have been satisfactory, with seven wounds totally dry, and 37 resurfaced sufficiently so as to make the amount of drainage negligible. Four patients had results classified as poor.