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10.1245/ASO.2005.03.100
Annals of Surgical Oncology 12:104-110 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Rectus Flap Reconstruction Decreases Perineal Wound Complications After Pelvic Chemoradiation and Surgery: A Cohort Study

David B. Chessin, MD1, John Hartley, MD1, Alfred M. Cohen, MD1, Madhu Mazumdar, PhD2, Peter Cordeiro, MD3, Joseph Disa, MD3, Babek Mehrara, MD3, Bruce D. Minsky, MD4, Philip Paty, MD1, Martin Weiser, MD1, W. Douglas Wong, MD1 and Jose G. Guillem, MD, MPH1

1 Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
2 Department of Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
3 Plastic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
4 Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021

Correspondence: Address correspondence and reprint requests to: Jose G. Guillem, MD, MPH; E-mail: guillemj{at}mskcc.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: A major source of morbidity after abdominoperineal resection (APR) after external beam pelvic radiation is perineal wound complications, seen in up to 66% of cases. Our purpose was to determine the effect of rectus abdominus myocutaneous (RAM) flap reconstruction on perineal wound morbidity in this population.

Methods: The study group consisted of 19 patients with anorectal cancer treated with external beam pelvic radiation followed by APR and RAM flap reconstruction of the perineum. A prospectively collected database was queried to identify a control group (n = 59) with anorectal cancer treated with similar radiation doses that subsequently underwent an APR without a RAM flap during the same time period. Comparison of percentages was performed with a two-sided Fisher’s exact test, and comparison of means was performed with Wilcoxon’s test.

Results: Perineal wound complications occurred in 3 (15.8%) of the RAM flap patients and 26 (44.1%) of the control patients (P = .03). The incidence of other complications was not different between groups (42.1% vs. 42.4%; P = .8). Despite an increased number of anal squamous tumors, an increased vaginectomy rate, increased use of intraoperative radiotherapy, and an increased proportion of cases with recurrent disease, the flap group had a significantly lower rate of perineal wound complications relative to the control group.

Conclusions: Perineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.

Key Words: Rectal cancer • Perineal wound • Radiotherapy • Rectus abdominus myocutaneous flap


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Traditional management of the nonhealing perineal wound after abdominoperineal resection (APR), noted in 7% to 66% of cases, includes débridement, excision, and closure or local wound care, an approach that requires a substantial time commitment from the surgeon and patient and often fails.1–13 Possible factors that lead to the increase in perineal wound complications are related to the large, noncollapsable dead space created by resection in the pelvis, compounded by primary wound-healing problems in an irradiated, poorly vascularized field.6,8 In an attempt to decrease the rate of wound complications after APR, surgeons have developed the technique of myocutaneous flap coverage of the perineum.6,7,9,14–17 Myocutaneous flap reconstruction achieves perineal closure with well-vascularized, nonirradiated tissue and fills the pelvic dead space with bulky, healthy tissue, thus improving wound healing and decreasing infection rates. In addition, the myocutaneous tissue helps resist infection, increases oxygen tension, and improves leukocyte delivery and function in the region of the perineal wound.6

One type of myocutaneous flap used for perineal wound reconstruction after rectal extirpative surgery is based on the rectus abdominis muscle.17–23 The advantages of the rectus abdominus myocutaneous (RAM) flap include a wide arc of rotation based on the consistent inferior epigastric artery pedicle, large tissue bulk, consistent viability, minimal donor site morbidity, and the relative ease and speed with which the flap can be raised. In addition, the RAM flap can be used to reconstruct the vagina in sexually active women and to decrease the periurethral fibrosis and contraction associated with anorectal resection.24 The purpose of this study was to determine the effect of perineal wound closure with a RAM flap on perineal wound morbidity after preoperative combined modality therapy (CMT) and APR for anorectal cancer.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patient Population
From 1991 to 2003, 433 patients with anorectal cancer were treated with APR at Memorial Sloan-Kettering Cancer Center (MSKCC). These patients were identified from the prospectively collected Colorectal Service and Plastic Surgery Service databases. Two hundred six patients were treated with preoperative pelvic radiation plus chemotherapy at MSKCC. Of these patients, 19 were treated with APR and RAM flap reconstruction of the perineum. The Colorectal Service database was queried to identify a control group (n = 59) with anorectal cancer treated at MSKCC with similar radiation doses who subsequently underwent an APR with primary perineal closure during the same time period. Patients who received preoperative radiotherapy at other institutions were excluded from our analysis, because we could not control for technique of delivery.

The Colorectal Service database, supplemented by a comprehensive chart review, was used to determine postoperative perineal wound complications, defined as evidence of perineal wound infection, breakdown, or both. Age, sex, use of intraoperative radiotherapy, postoperative tumor stage, resection margins, location of tumor (anal vs. rectal), length of hospitalization, and incidence of complications not related to the perineal wound were determined and compared between groups.

Time to complete wound healing, as documented in the medical record by the operating surgeon, was recorded. Complete wound healing was defined as intact skin with no discharge or clinical signs of infection (erythema, tenderness, or fluctuance). Perineal wound separation was defined as skin and subcutaneous tissue breakdown with no signs of infection. A superficial perineal wound infection was defined as cellulitis with no evidence of deep tissue infection. A deep perineal wound infection was defined as infection extending deep to the subcutaneous tissue. Patients with a wound infection requiring incision and drainage or resulting in a persistent perineal sinus were categorized as deep wound infections. Perineal wounds with skin dehiscence or signs of infection were treated with standard surgical wound care techniques, including incision and drainage of collections as clinically indicated. The study was reviewed and approved by the MSKCC Institutional Review Board.

Technique of RAM Flap Construction
The RAM flap, derived from the rectus abdominus muscle, is mobilized by raising a supraumbilical skin paddle with underlying fat and rectus muscle. The right rectus muscle is preferentially chosen to allow for colostomy siting through the left rectus muscle. Perforating vessels through the anterior rectus sheath are carefully dissected to minimize the fascial resection to allow primary closure of the defect created in the anterior rectus sheath.17 The blood supply to the RAM flap is via the deep inferior epigastric artery and vein, which is mobilized as a pedicle. Flap dissection is continued to the origin of the rectus abdominus muscle on the pubis. The muscle rarely requires disinsertion to reach the pelvis. Disinsertion, if performed, should be performed with extreme care to avoid tension or twisting of the vascular pedicle.

Once fully mobilized, the flap is passed through the abdominal incision and fashioned into the perineal defect. The rectus abdominus muscle is used to fill the defect created in the pelvic floor, and the skin is used to repair the external defect. The flap is secured in place without tension by using multiple layers of sutures. The defect created in the right anterior rectus sheath is usually repaired primarily with minimal tension. The use of mesh is usually avoided because this may result in infections in a contaminated abdominal wound. In our institution, closed-suction pelvic drainage is achieved transabdominally. The basic steps of construction of a RAM flap are summarized in Fig. 1Go.



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  		FIG. 1. Steps in the creation of a rectus abdominus myocutaneous (RAM) flap.24 (A) RAM flap designed over the rectus abdominus muscle, including the overlying fat and skin. The RAM flap has been fully mobilized, with an inferior epigastric artery pedicle. (B) Transabdominal passage of the RAM flap, sized to reconstruct the vagina and perineal wound. (C) RAM flap secured in place with absorbable sutures placed in layers. It is important to note that tension or twisting of the vascular pedicle must be avoided. (D) Closed abdominal and perineal wounds. In our institution, pelvic drainage is achieved with a closed-suction system passed transabdominally. Reprinted with permission [ Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg 2002;110(4):1058–65[Medline]].

 
In most cases, patients were selected for RAM flap reconstruction of the perineum on the basis of the need for vaginectomy or a prolonged interval between completion of CMT and surgery, because this seems to increase the likelihood of perineal wound breakdown. In addition, patients with anal tumors necessitating resection of a large amount of perineal skin were considered for flap closure. It must be emphasized, however, that the final decision to use a flap was multifactorial because, at the time, we did not have any definitive clinical guidelines for its use.

Statistical Analysis
For categorical variables such as sex, stage, type of tumor, need for concomitant vaginectomy, margins, and various types of wound complications, equality of proportion from each category belonging either to the flap group or the control group was tested with a two-sided Fisher’s exact test. Equality of mean for age and time from radiation to surgery was tested with Wilcoxon’s test. Data were analyzed with SPluS software (Insightful Corp., Seattle, WA). A P value of ≤.05 was considered statistically significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient Population
The study group consisted of 19 patients (rectal adenocarcinoma [n = 12] and recurrent or persistent anal squamous carcinoma [n = 7]). The median time from the completion of radiation to surgery was 62 days (range, 25–3285 days). The broad range is because our patient population included those undergoing surgery shortly after completion of preoperative radiation for a primary tumor and those undergoing surgery for recurrent tumors years after the completion of radiation. All patients in the flap group received concurrent chemotherapy (5-fluorouracil based, n = 17; CPT-11 based, n = 2) before radical resection.

The control group consisted of 59 patients (rectal adenocarcinoma [n = 56] and recurrent or persistent anal squamous carcinoma [n = 3]). The median time from completion of radiation to surgery was 48 days (range, 31–326 days). All patients in the control group received concurrent chemotherapy (5-fluorouracil based, n = 52; irinotecan based, n = 7).

All patients received external beam radiotherapy (median dose, 5040 cGy; range, 4500–5940 cGy at 180 cGy/day) delivered at a single institution (MSKCC) according to previously published techniques. 25 By using 15-MV photons, a three- or four-field technique was used. The perineum was blocked as much as possible in the lateral fields.

The study and control groups were matched for demographic variables (age, postoperative tumor stage, and margin status). The mean age in the RAM flap group was 56.5 years (range, 32–74 years) and in the control group was 60.3 years (range, 25–80 years). The mean age was not significantly different between groups (P = .3). There were 17 women (89%) in the RAM flap group and 21 women (36%) in the control group (P < .001). There was no significant difference between the RAM flap group and the control group with regard to major comorbidities that can potentially impair wound healing (Table 1Go). In addition, there was no significant difference between groups concerning the mean length of hospitalization (RAM flap group, 12.2 days; control group, 11.3 days; P = .7).


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  		TABLE 1. Patient comorbidities that may affect perineal wound healing
 
Factors perceived to be associated with a potentially larger perineal defect—including lower tumor (anal vs. rectal), resection of a recurrent tumor, tumor requiring a vaginectomy, use of intraoperative radiotherapy, and increased length of time from radiation to surgery—were significantly increased in the RAM flap group (Table 2Go).


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  		TABLE 2. Summary of therapeutic and pathologic characteristics of the flap and control groups
 
There were three patients with stage IV disease in the flap group; one had APR for palliation, and two had concomitant potentially curative resection of metastases. There were six patients with stage IV disease in the control group; five had APR for palliation, and one had concomitant potentially curative resection of metastases. Stage IV patients were included because they survived long enough to achieve perineal wound healing, which was the primary end point of the study.

Perineal Wound Complications
There were 3 (15.8%) perineal wound complications in the RAM flap group, as compared with 26 (44.1%) in the control group (P = .03). In the RAM flap group, one patient had a superficial separation that resolved with local wound care. A second patient had wound cellulitis that responded to antibiotics. The final patient had a subcutaneous abscess that resolved after bedside incision and drainage and antibiotics. In the control group, nine patients (15.3%) had a perineal wound separation with no signs of infection, eight patients (13.5%) had a superficial perineal wound infection, and nine patients (15.3%) had a deep perineal wound infection.

The median time to perineal wound healing was 43 days (range, 15–225 days) in the RAM flap group and 39.5 days (range, 15–1035 days) in the control group (P = .4). However, the time to perineal wound healing was substantially longer in the subgroup of patients who had a perineal wound complication compared with those did not experience a perineal wound complication. The median time to perineal wound healing in the subgroup of flap patients who experienced a perineal wound complication was 65 days (range, 53–165 days). The median time to perineal wound healing in the subgroup of control patients who experienced a perineal wound complication was 92 days (range, 39 days to never healed). All patients in the RAM flap group ultimately experienced complete perineal wound healing, and 58 patients in the control group (98%) ultimately experienced complete perineal wound healing. However, one patient died of medical comorbidities 4 months after surgery, before perineal wound healing.

Other Complications
Eight (42.1%) complications were unrelated to the perineal wound in the flap group, compared with 25 (42.4%) in the control group (P = .8; Table 3Go). Complications related to the abdominal wound were not significantly different between groups (study group, 10.5%; control group, 15.3%; P = .8). There were no ventral hernias in the study group (0%), compared with two in the control group (3.4%; P = 1.0). Complication data are listed in Table 4Go.


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  		TABLE 3. Summary of complications unrelated to the perineal wound in the flap and control groups
 

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  		TABLE 4. Summary of wound and nonwound complications in the flap and control groups
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The data presented in this study suggest that perineal wound complications may be decreased by RAM flap reconstruction after APR in patients who have received preoperative pelvic radiation. In the RAM flap group, 15.8% of patients experienced a perineal wound complication; this is significantly lower than the 44.1% reported for the control group. This compares favorably to a recent report of a heterogeneous group of patients that documented a 17.8% perineal wound complication rate after RAM flap reconstruction.17

In our study, the RAM flap group included significantly more patients with anal tumors, recurrent tumors, and need for a concomitant vaginectomy, thus suggesting that the RAM flap group required more extensive pelvic dissection and perineal resection. In addition, the radiation-to-surgery interval was longer in the RAM flap group, and this likely increased pelvic fibrosis and difficulty of dissection. However, despite this unfavorable selection bias, the incidence of perineal wound complications was decreased in the flap group.

Theoretical concerns with creation of a RAM flap include the potential for an increased incidence of complications, especially associated with the abdominal wound. A recent series examining RAM flap closure of the perineum for anal cancer in 14 patients reported no perineal wound complications but reported a 14% rate of major complications related to the abdominal incision.3 Our data suggest that there is no increase in morbidity related to the RAM flap donor site. In fact, we documented no ventral hernias, and the abdominal wound infection and small-bowel obstruction rates were not significantly different when the flap group was compared with the control group. In addition, the rate of complication unrelated to the perineal wound was not different between groups.

There have been reports of other types of myocutaneous flaps for perineal wound reconstruction. A recent report7 of 16 patients undergoing APR and intraoperative radiotherapy and perineal reconstruction with a gracilis flap showed an overall perineal complication rate of 37%. In addition, gracilis flaps have an inconsistent blood supply and a limited arc of rotation and often lack the bulk required for adequate obliteration of the pelvic dead space.7 Other studies have examined inferior gluteal myocutaneous flaps for perineal reconstruction. These flaps are associated with perineal wound complications in up to 44% of cases.8 The omental pedicle flap has also been used to obliterate the pelvic dead space associated with anorectal resection.26,27 Unfortunately, omental size and mobility are inconsistent, and although the flap is useful in the obliteration of pelvic dead space, it does not address the irradiated, poorly vascularized perineal tissue that is closely associated with perineal wound morbidity.

Several limitations of this study deserve comment. First, although well matched for age and external beam pelvic radiation dosimetry, this cohort study, which compared the study group with historical controls, has the inherent bias typical of any retrospective study. The study and control groups were significantly different in several clinical and pathologic variables. In addition, there was a wide range in the interval from radiation to surgery in the flap group. This was due to the inclusion of patients who had radiotherapy for their primary tumor and had flap reconstruction of the perineum for a recurrent tumor months to years after completion of radiation. Although the flap group was heterogeneous, the variables present in increased numbers may lead, in part, to a more complex environment for perineal wound healing. We interpret this finding as further support of the benefit of RAM flap perineal closure.

In summary, RAM flap reconstruction of the perineum after pelvic chemoradiation and surgery decreases perineal wound complications. Insofar as nonperineal wound complications and other morbidities are not increased, RAM flap closure of the perineum should be strongly considered in patients with anorectal cancer treated with preoperative CMT followed by APR. Future large prospective studies may help to better define factors associated with an increased risk of perineal wound morbidity after preoperative CMT and, thus, guide selection of patients who will likely benefit from RAM flap perineal reconstruction.


   FOOTNOTES
 
Presented at the Society of Surgical Oncology’s 57th Annual Cancer Symposium, New York, New York, March 2004.

Received for publication March 29, 2004. Accepted for publication September 29, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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