Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps

Original article

Perineal reconstruction after abdominoperineal excisionusing inferior gluteal artery perforator flaps

A. Hainsworth1, M. Al Akash1, P. Roblin2, P. Mohanna2, D. Ross2 and M. L. George1

Departments of 1Colorectal and 2Plastic Surgery, St Thomas’ Hospital, London, UKCorrespondence to: Miss A. Hainsworth, Department of Surgery, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK(e-mail: [email protected])

Background: Perineal wound complications following abdominoperineal excision (APE) for low rectaltumours remain an important cause of morbidity and prolonged hospital stay, particularly afterchemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator(IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors’ previousexperience and published literature on myocutaneous flaps.Methods: A series of patients who underwent immediate IGAP flap reconstruction after APE betweenApril 2008 and December 2010 were examined retrospectively to determine patient demographics,length of operation, complications (perineal wound and general) and length of hospital stay.Results: Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwentimmediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvantchemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APEplus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patientshad multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacralresection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and fourmajor flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Medianlength of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAPflaps. Late complications occurred in two patients who had vaginal reconstruction and developed perinealhernias requiring revisional surgery.Conclusion: Although operating times are long, the IGAP flap is robust, with no flap necrosis observedin this series.

Presented to the International Surgical Congress of the Association of Surgeons in Great Britain and Ireland, Liverpool,UK, April 2010, and the Royal Society of Medicine Coloproctology Symposium, London, UK, January 2010

Paper accepted 31 October 2011Published online 9 January 2012 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7822

Introduction

Radical pelvic surgery is used increasingly to treatlocally advanced or recurrent rectal carcinoma to achievelong-term survival1,2. In comparison with standardsurgery, extralevator abdominoperineal excision (APE)3

is associated with a reduction in circumferential margininvolvement but an increase in perineal wound complica-tions, from 20 to 38 per cent4. Preoperative radiotherapydecreases local recurrence rates5–10, but doubles the rateof total and major perineal wound complications11,12. Anevidence-based review of 36 studies supported the use of

single-stage reconstruction after APE in the presence ofchemoradiotherapy to reduce wound morbidity13; how-ever, others have reported a primary tension-free repairwith low morbidity14.

The use of myocutaneous flaps (vertical rectus abdominis(VRAM)/gracilis flaps) reduces the length of hospital stayand the perineal wound complication rate15–19. However,VRAM flaps are not suitable for laparoscopic APE, havea flap failure rate of 2·3–10 per cent13,15, a major woundcomplication rate of 15–22 per cent16,17,20,21 and a highrate of donor-site morbidity13,15,21. The inferior glutealartery perforator (IGAP) flap, which allows the transfer

2012 British Journal of Surgery Society Ltd British Journal of Surgery 2012; 99: 584–588Published by John Wiley & Sons Ltd

Perineal reconstruction after abdominoperineal excision 585

of skin and fat but is muscle-sparing22,23, provides a goodoption for perineal reconstruction24. This study examinedthe outcome of patients with IGAP flaps.

Methods

Data on successive patients from April 2008 to December2010 undergoing prone extralevator APE or multivisceralAPE (MVR) for rectal adenocarcinoma with immediateIGAP flap reconstruction were collected retrospectively.Patients having APE for gynaecological malignancy (4patients), salvage anal cancer surgery (3) or with morbidobesity (1) were excluded. Data were collected on patientdemographics, pathology, chemoradiotherapy, type andlength of operation, length of hospital stay, postoperativecomplications (flap-related and general) and length offollow-up. Major wound complications were defined asany wound requiring reoperation or readmission11.

The rectum was mobilized, laparoscopically or by anopen technique, in the mesorectal plane towards the pelvicfloor, the abdomen was closed and an end colostomymatured. An extralevator perineal dissection was performedwith the patient prone, and the plastics team raisedthe IGAP flaps. These IGAP flaps were fasciocutaneousperforator flaps and designed in a V-Y fashion, with thelower border placed in the buttock crease and the lateralextension medial to the greater trochanter.

The flaps were raised from lateral to medial ina subfascial plane. This allowed identification of theperforating vessels passing through the muscle into theflap (Fig. 1). At the junction of the lateral and middle thirdsof the flap, a consistent lateral perforator vessel was usuallyidentified. This was isolated and dissected down betweenthe muscle fibres to allow it to move freely. Once this vesselhad been dissected and preserved, the flap was raised fromthe medial border. Perforators in the medial and centralareas of the flaps were isolated. The number of perforatorsused and the degree to which they were dissected free fromtheir muscular attachments was determined by the degreeof medial transposition required.

The flaps were advanced medially. The first flap wasadvanced into the pelvis and the buried portion de-epithelialized. This was secured superiorly to the anteriorsurface of the sacrum and the remaining pelvic outlet. Thecontralateral flap was advanced medially to close the woundin a double-breasted fashion. The leading medial edge ofthis flap was rolled over internally and de-epithelialized,placing the resultant suture line vertically in the midline torecreate the natal cleft (Fig. 2). The wounds were closed inlayers and a suction drain placed bilaterally (removed onday 6).

Fig. 1 The perforating vessels pass through the muscle into theflap (arrows)

Fig. 2 The first flap is buried deep inside the pelvis and thecontralateral flap is advanced medially to close the wound in adouble-breasted fashion. The resultant suture line recreates thenatal cleft

For women undergoing posterior vaginectomy, vaginalreconstruction could be performed. Where the anteriorvaginal wall remained, the medial flap edges were suturedto its lateral edges. In total vaginectomy, the leading medialedges of both flaps were not de-epithelialized as these wererotated internally and laterally to create the neovagina.

After surgery a supine position was avoided for the first24 h and sitting was avoided for 4 days. The flaps werereviewed daily by the plastics team and wound swabs takenif indicated. The patients were allowed to mobilize on thefirst postoperative day. They were placed in a compressiongarment continuously for 2 weeks and then during the dayfor the next 2 weeks. All patients were supplied with apressure-relieving cushion.

2012 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2012; 99: 584–588Published by John Wiley & Sons Ltd

586 A. Hainsworth, M. Al Akash, P. Roblin, P. Mohanna, D. Ross and M. L. George

Table 1 Patient and surgical details

Primary rectalcancer (n = 33)

Recurrent rectalcancer (n = 7)

Duration ofsurgery (min)*

Length of hospitalstay (days)*

Age (years)* 67 (28–79) 64 (44–75)Sex ratio (M : F) 25 : 8 3 : 4Chemoradiotherapy 32 7Type of operation

APE (n = 32; 25 open, 7 laparoscopic) 402 (210–568) 13 (6–28)APE 27 1 392 (240–568)Panproctocolectomy/APE 2 0 427·5 (360–495)APE and lymphoma splenectomy 1 0 504Perineal excision 0 1 210

MVR (n = 8) 561 (350–636) 27 (11–140)Total pelvic exenteration 3 4 553 (360–608)Abdominosacral resection 0 1 636

Overall (n = 40) 33 7 417 (210–636) 14 (6–140)

*Values are median (range). APE, abdominoperineal excision; MVR, multivisceral resection.

The research and development department of Guy’s andSt Thomas’ NHS Foundation Trust approved the use ofpatients’ data for this study.

Results

Forty patients underwent perineal excision with immediateIGAP flap reconstruction (4 with vaginal reconstruction)for rectal adenocarcinoma; 33 had primary rectal cancer(32 of whom received neoadjuvant chemoradiotherapy) andseven had recurrent rectal cancer (all received neoadjuvantchemoradiotherapy). Type of operation, duration ofsurgery and length of hospital stay are shown in Table 1.Median length of follow-up was 9 (range 3–28) months.

Flap complications

There were four major flap complications (10 per cent).One patient undergoing TPE for recurrent rectal cancerdeveloped sepsis secondary to an enteroperineal fistulacaused by a drain. Despite laparotomy, exteriorization ofthe fistula, multiple debridements, vacuum-assisted closure(VAC) dressings and appropriate antibiotics, the patientdied 4 months later from sepsis and malnutrition. Onepatient undergoing TPE was taken back to theatre fordebridement and VAC therapy.

Two other patients undergoing APE initially madean uneventful recovery, but were readmitted 4 days afterdischarge with deep-seated wound infections beneath theIGAP flaps. Both required return to theatre, one for asingle washout and the other for debridement and VACtherapy. Both recovered well, with minimal discomfort andearly mobilization.

There were four minor wound complications (10 percent). Two patients had cellulitis surrounding the woundthat required oral antibiotics. Two patients had an areaof superficial wound dehiscence; one healed withoutintervention and the other required closure under localanaesthetic.

Two of four women developed perineal hernias 18 and22 months after vaginal reconstruction and underwentrevisional surgery using a Surgisis Biodesign

TMmesh

(Cook Medical, Bloomington, Indiana, USA).

Other complications

One patient died from multiple organ failure on day 13 aftersurgery in the intensive care unit, following a stroke. Twopatients developed prolonged ileus, one an intra-abdominalcollection that required computed tomography-guideddrainage and one a urinary leak from an ileal conduitthat required nephrostomies and ureteric stents.

Discussion

The treatment of lower-third rectal cancer with preop-erative chemoradiotherapy and extralevator APE resultsin a large perineal defect with a risk of perineal woundcomplications. Previous studies using myocutaneous flapshave shown a decrease in perineal wound morbidity13,15

and a reduced length of hospital stay15. However, there isflap failure13,15, donor-site morbidity21 and incompatibilitywith laparoscopic APE.

The present report is the largest series of immediateperineal reconstruction using IGAP flaps following radicalsurgery for rectal cancer published to date. Rates of flapnecrosis were lower than with myocutaneous flaps15. With


Perineal reconstruction after abdominoperineal excision 587

39 (98 per cent) of the 40 patients having preoperativechemoradiotherapy, the total wound complication rate (8of 40, 20 per cent) was comparable to that of previouslypublished series of myocutaneous flaps16–18,21. Operatingtimes were longer with the IGAP flap than for othermyocutaneous flaps15. This is because coloproctologistsand plastic surgeons can operate simultaneously whenperforming a VRAM or gracilis flap, but this is not possiblewith IGAP flaps.

Donor-site morbidity for perforator artery flaps islow22,25. Unlike the VRAM flap, IGAP flaps are compatiblewith both laparoscopic and open surgery, do not interferewith stoma formation1 and carry no increased risk ofabdominal hernia15. The IGAP flap avoids the use ofirradiated tissue and enables the import of local vascularizedtissue to provide a bulky, robust flap for reconstruction ofthe irradiated perineum and neovagina1. Myocutaneousflaps have more initial bulk as muscle is taken with thefasciocutaneous component of the flap, but this muscleatrophies with time and it seems unnecessary to takemuscle as this adds to morbidity and pain. In addition,when raising the IGAP flap there is no transection of thegluteus maximus muscle1,22–24,26,27.

There are still questions surrounding sexual functionfollowing vaginal reconstruction with IGAP flaps. Arecent study reported that all 14 women undergoingperineal reconstruction with inferior or superior glutealartery perforator flaps following perineal cancer resectionresumed sexual intercourse1. This compares with findingsin a series using VRAM flaps for reconstruction, where85·2 per cent resumed sexual activity28.

Neovaginal reconstruction affords not only psycho-social benefit but the incorporation of healthy tissue intothe pelvic cavity1,29,30. This has been shown previouslyto decrease the incidence of fistula, small bowel obstruc-tion, infection and haemorrhage29,30. Unfortunately, twowomen who had uncomplicated surgery developed post-operative perineal herniation. This was managed with meshsacrocolpopexy in one patient and a ‘mesh cradle’ suturedat the pelvic brim in the other. The authors hypothesizethat this herniation was related to construction of the neo-vagina, whereby it is more difficult to securely fixate thetissue deep inside the pelvis and to obliterate the pelvicdead space. They now take measures at primary operationto prevent this from occurring, by using an internal meshto suspend the small bowel out of the pelvis.

Follow-up in this small study of 40 patients was short,and longer-term data are required to assess donor-sitemorbidity with regard to pain, discomfort and perinealherniation. This was not a randomized controlled trialcomparing VRAM with IGAP flaps, and the data have

been compared with outcomes from other studies thatincluded more patients with anal cancer and variable ratesof radiotherapy. Nevertheless, this experience has shownthat the IGAP flap is a reliable and safe option for perinealand vaginal reconstruction.

Disclosure

The authors declare no conflict of interest.

References

1 Wagstaff MJ, Rozen WM, Whitaker IS, Enajat M,Audolfsson T, Acosta R. Perineal and posterior vaginal wallreconstruction with superior and inferior gluteal arteryperforator flaps. Microsurgery 2009; 29: 626–629.

2 Ferron G, Martel P, Querleu D. [Vaginal reconstructionafter pelvic exenteration: when and which techniques?] BullCancer 2003; 90: 435–440.

3 Shihab OC, Heald R, Rullier E, Brown G, Holm T,Moran BJ. Defining the surgical planes on MRI improvessurgery for cancer of the low rectum. Lancet Oncol 2009; 10:1207–1211.

4 West NP, Anderin C, Smith KJ, Holm T, Quirke P;European Extralevator Abdominoperineal Excision StudyGroup. Multicentre experience with extralevatorabdominoperineal excision for low rectal cancer. Br J Surg2010; 97: 588–599.

5 Gerard A, Buyse M, Nordlinger B. Preoperativeradiotherapy as adjuvant treatment in rectal cancer. Finalresults of a randomised study of the European Organisationfor Research and Treatment of Cancer (EORTC). Ann Surg1988; 208: 606–614.

6 Stockholm Rectal Cancer Study Group. Preoperative shortterm radiation therapy in operable rectal carcinoma. Aprospective randomized trial. Cancer 1990; 66: 49–55.

7 Garcia-Aguilar J, Hernandez de Anza E, Sirivongs P,Lee SH, Madoff RD, Rothenberger DA. A pathologicalcomplete response to preoperative chemoradiation isassociated with lower local recurrence and improved survivalin rectal cancer patients treated by mesorectal excision. DisColon Rectum 2003; 46: 298–304.

8 Theodoropoulos G, Wise W, Padmanabhan A, Kerner BA,Taylor CW, Aguilar PS. T-level downstaging and completepathological response after preoperative chemoradiation foradvanced rectal cancer result in decreased recurrence andimproved disease free survival. Dis Colon Rectum 2004; 47:279–286.

9 Janjan N, Khoo V, Abbruzzese J. Tumor downstaging andsphincter preservation with preoperative chemoradiation inlocally advanced rectal cancer: the M. D. Anderson CancerCenter experience. Int J Radiat Oncol Biol Phys 1999; 44:1027–1038.

10 Crane CH, Skibber JM, Feig BW, Vauthey JN,Thames HD, Curley SA et al. Response to preoperative


588 A. Hainsworth, M. Al Akash, P. Roblin, P. Mohanna, D. Ross and M. L. George

chemoradiation increases the use of sphincter-preservingsurgery in patients with locally advanced low rectal cancer.Cancer 2003; 97: 517–524.

11 Bullard KM, Trudel JL, Baxter NN, Rothenberger DA.Primary perineal wound closure after preoperativeradiotherapy and abdominoperineal resection has a highincidence of wound failure. Dis Colon Rectum 2005; 48:438–443.

12 El-Gazzaz G, Kiran RP, Lavery I. Wound complications inrectal cancer patients undergoing primary closure of theperineal wound after abdominoperineal resection. Dis ColonRectum 2009; 52: 1962–1966.

13 Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of thepelvis after abdominoperineal excision. Colorectal Dis 2008;11: 806–816.

14 Bebenek M. Abdominosacral amputation of the rectum(ASAR) for low rectal cancers – ten years of experience. AnnSurg Oncol 2009; 16: 2211–2217.

15 Chan S, Miller M, Ng R, Ross D, Roblin P, Carapeti E et al.The use of myocutaneous flaps for perineal closure followingabdominoperineal excision of the rectum foradenocarcinoma. Colorectal Dis 2010; 12: 555–560.

16 Buchel EW, Finical S, Johnson C. Pelvic reconstructionusing rectus abdominis musculocutaneous flaps. Ann PlastSurg 2004; 52: 22–26.

17 Chessin DB, Hatley J, Cohen AM, Mazumdar M,Cordeiro P, Mehara B et al. Rectus flap reconstructiondecreases perineal wound complications after pelvicchemoradiation: a cohort study. Ann Surg Oncol 2005; 12:104–110.

18 Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E.Primary rectus abdominis myocutaneous flap for repair ofperineal and vaginal defects after extended abdominoperinealresection. Br J Surg 2005; 92: 482–486.

19 Lefevre J, Parc Y, Kemeis S, Shields C, Touboul E,Chaouat M et al. Abdomino-perineal resection for analcancer: impact of a vertical rectus abdominis myocutaneousflap on survival, recurrence, morbidity and wound healing.Ann Surg 2009; 250: 707–711.

20 Goldberg GL, Sukumvanich P, Einstein MH, Smith HO,

Anderson PS, Fields AL. Total pelvic exenteration: theAlbert Einstein College of Medicine/Montefiore MedicalCenter experience (1987 to 2003). Gynecol Oncol 2006; 101:261–268.

21 Nelson RA, Butler CE. Surgical outcomes of VRAM versusthigh flaps for immediate reconstruction of pelvis andperineal cancer resection defects. Plast Reconstr Surg 2009;123: 175–183.

22 Scheufler O, Farhadi J, Kovach SJ, Kukies S, Pierer G,Levin LS et al. Anatomical basis and clinical application ofthe infragluteal perforator flap. Plast Reconstr Surg 2006; 118:1389–1400.

23 Kim YS, Lew DH, Roh TS, Yoo WM, Lee WJ, Tark KC.Inferior gluteal artery perforator flap: a viable alternative forischial pressure sores. J Plast Reconstr Aesthet Surg 2009; 62:1347–1354.

24 Sinna R, Qassemyar Q, Benhaim T, Lauzanne P, Sabbagh C,Regimbeau JM et al. Perforator flaps: a new option inperineal reconstruction. J Plast Reconstr Aesthet Surg 2010;63: 766–774.

25 Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforatorflaps: history, controversies, physiology, anatomy, anduse in reconstruction. Plast Reconstr Surg 2009; 123:132e–145e.

26 Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sorereconstruction using an inferior gluteal artery perforator(IGAP) flap. Br J Plast Surg 2002; 55: 83–85.

27 Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S,Ikeda A. The gluteal perforator-based flap for repair of sacralpressure sores. Plast Reconstr Surg 1993; 91: 678–683.

28 Casey WJ III, Tran NV, Petty PM, Stulak JM, Woods JE.A comparison of 99 consecutive vaginal reconstructions: anoutcome study. Plast Surg 2004; 52: 27–30.

29 Benson C, Soisson AP, Carlson J, Culbertson G,Hawley-Bowland C, Richards F. Neovaginal reconstructionwith a rectus abdominis myocutaneous flap. Obstet Gynecol1993; 81: 871–875.

30 Judge B, Garcıa-Aguilar J, Landis GH. Modification of thegluteal perforator-based flap for reconstruction of theposterior vagina. Dis Colon Rectum 2000; 43: 1020–1022.


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Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps