UvA-DARE (Digital Academic Repository) Management of early extralevator abdominoperineal resection

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  • UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)

    UvA-DARE (Digital Academic Repository)

    Management of early neoplasms and surgical complications of the rectum

    Musters, G.D.

    Link to publication

    Citation for published version (APA): Musters, G. D. (2016). Management of early neoplasms and surgical complications of the rectum.

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    Download date: 29 Jul 2020

    https://dare.uva.nl/personal/pure/en/publications/management-of-early-neoplasms-and-surgical-complications-of-the-rectum(89bbd85f-5615-48d7-b464-b858683a091a).html

  • CHAPTER 2 Perineal wound healing after abdominoperineal resection for rectal cancer; a systematic review and meta-analysis G.D Musters, C.J. Buskens, W.A. Bemelman, and P.J. Tanis

    Dis Colon Rectum 2014;57(9):1129-1139.

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    ABSTRACT

    Aim: The primary aim of this systematic review with meta-analysis was to determine the impact of neoadjuvant (chemo)radiotherapy and an extralevator approach on perineal wound healing after abdominoperineal resection for rectal cancer.

    Methods: In March 2014, electronic databases were searched. Studies describing any outcome measure on perineal wound healing after abdominoperineal resection for rectal cancer were included. The primary endpoint was overall perineal wound problems within 30 days after conventional or extralevator abdominoperineal resection with or without neoadjuvant radiotherapy. Secondary endpoints were primary wound healing, perineal hernia rate, and the effect of biological mesh closure on perineal wound problems.

    Results: A total of 32 studies were included. The pooled percentage of perineal wound problems after primary perineal wound closure in patients who did not undergo neoadjuvant radiotherapy was 15.3% (95% Ci, 12.1–19.2) after conventional abdominoperineal resection and 14.8% (95% Ci, 9.5–22.4) after extralevator abdominoperineal resection. after neoadjuvant radiotherapy, perineal wound problems occurred in 30.2% (95% Ci, 19.2–44.0) after conventional abdominoperineal resection and in 37.6% (95% Ci, 18.6–61.4) after extralevator abdominoperineal resection. Radiotherapy significantly increased perineal wound problems after abdominoperineal resection (OR 2.22; 95% Ci, 1.45–3.40; p < 0.001). After biological mesh closure of the pelvic floor following extralevator abdominoperineal resection with neoadjuvant radiotherapy, the percentage of perineal wound problems was 7.3% (95% Ci, 1.5–29.3).

    Conclusion: Neoadjuvant radiotherapy significantly increases perineal wound problems after abdominoperineal resection for rectal cancer.

  • Perineal wound healing after abdominoperineal resection for rectal cancer

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    2

    INTRODUCTION

    Perineal wound problems after abdominoperineal resection (APR) for rectal cancer is reported in up to 57% of patients.1 If the perineum does not heal primarily, secondary wound healing may prolong hospital stay, may necessitate surgical reintervention, and often requires intensive wound care for several months, with the risk of developing a persistent sinus after 1 year.2–4 In the past decade, perineal wound healing after APR has gained more attention because of the intensified treatment of distal rectal cancer. After the widespread adoption of the technique of total mesorectal excision and the increasing use of neoadjuvant radiotherapy, locoregional disease control and survival of rectal cancer have improved.5,6 The oncological outcome remained poor due to positive circumferential resection margins and tumour perforations in patients with low rectal cancer undergoing APR.7 When the total mesorectal excision plane is followed all the way down to the pelvic floor, as performed in conventional APR (cAPR), a typical coning of the specimen occurs by which the resection margins are compromised. To overcome this problem, wider excisions with en bloc resection of the distal rectum, sphincter complex, and levator muscles have been introduced, resulting in a cylindrical specimen. This extralevator APR (eAPR) reduces the rate of positive resection margins and tumour perforation in distal rectal cancer, and improves oncological outcome.8,9

    As a downside of improved oncological outcome, both radiotherapy and extended resections have been suggested to increase perineal wound healing problems after APR.10 Therefore, the aim of this systematic review with meta-analysis was to determine the impact of these changes in rectal cancer management on perineal wound healing after APR. Secondarily, the recent introduction of biological mesh reconstruction of the pelvic floor, aiming at improved perineal wound healing and the prevention of perineal hernia, was evaluated.

    METHODS

    Search strategy All studies reporting on perineal wound healing after either cAPR or eAPR for rectal cancer were considered eligible for review. The electronic databases of the national institutes of health Pubmed (1952–2014), EMBASE (1984–2014), and Cochrane library (2008–2013) were systematically searched in March 2014. The following medical subject heading (mesh) terms were used; rectal neoplasms, rectal, neoplasms, abdomen, perineum, colorectal surgery, surgical procedures, operative, general surgery, wound healing, reconstructive surgical procedures, wounds, and injuries. Other search terms were abdominal perineal resection, abdominoperineal resection, abdominoperineal excision, abdominal perineal excision, perineum surgery, perineal surgery, primary healing, repair, wound, and healing. No restrictions considering patient age or technique of APR were applied. Anal cancer, benign disorders, gynaecological cancers, exenterative procedures, sacral resections, use of myocutaneous flaps for perineal closure, delayed perineal wound closure, animal studies, non-English articles, congress abstracts, studies before 1990, previously published data, and studies with fewer than 5 patients were excluded. Of the initially identified publications, titles and abstracts

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    were screened to exclude nonrelated publications. Then, the full text of the remaining articles was read to determine whether they were eligible for inclusion. Of the included articles, the references were cross-checked to identify any additional studies of interest. Studies were included by two independent authors (G.M., P.T.). Any disagreements between both reviewers were resolved by consultation with an expert specialist (W.B.).

    Outcome parameters The primary end point was the percentage of overall perineal wound problems within 30 days after cAPR or eAPR with or without neoadjuvant radiotherapy. Besides this combined end point, a distinction between superficial (wound infection and dehiscence) and deep perineal wound problems (perineal abscess and presacral abscess) was made if relevant data were provided by the selected articles. Secondary outcome measures were superficial perineal wound problems, deep perineal wound problems, primary wound healing rate, perineal hernia rate at the end of follow- up, and the effect of biological mesh assisted closure on perineal wound problems and perineal hernia. Primary wound healing was included as a secondary end point, because this is not always the complement of perineal wound problems. For example, a seroma or hematoma may be present, while the perineal wound has been healed primarily. Furthermore, some studies only report on perineal wound healing rate without mentioning the perineal wound complications.

    Validity and eligibility assessment All included studies were assessed for methodological quality and risk of bias. For cohort studies, the Newcastle Ottawa quality assessment scale for cohort studies was used to assess risk of bias.11 The quality items scored were as follows: representativeness of the exposed cohort, selection of the nonexposed cohort, ascertainment of exposure, the absence of outcome of interest at the start of the study, comparability of the design or analysis, assessment of outcome, duration of follow-up and lost to follow-up. For randomised controlled trials (RCTs), the Jadad scoring system was used to assess the risk of bias.12 When the randomised groups of the RCTs were not used as described in the RCT, the Newcastle Ottawa quality assessment scale for cohort studies was also used to assess risk of bias.11

    Data extraction Two authors independently extracted data from the included studies (G.M., P.T.). Disagreements were resolved by discussion between the two reviewers. If no consensus could be reached, a third specialist author was consulted and decided (W.B.). In the case of RCTs on oncological interventions in which perineal wound healing was a secondary outcome parameter, data of both arms of the trial were combined or data from the appropriate arm was us