Filling and Reconstruction ESSO2008

7/31/2019 Filling and Reconstruction ESSO2008

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Filling and reconstruction

Hans de Wilt, MD, PhD.

Department of Surgical Oncology

Erasmus MC / Daniel den Hoed Cancer Center Rotterdam

Theo Wiggers, MD, PhD.

UMCG, Groningen

the Netherlands


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Perineal wound

Introduction

Surgical options

Surgical techniques

Take Home Message


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Woundinfections after APR

Radical resection (wide excision vs coning, exenteration)

Preoperative (chemo)radiation therapy

IORT


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Abdominoperineal resection

Holm et al. Br J Surg 2007


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Abdominoperineal resection


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Sometimes things go wrong


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Healing time > 3 months

Woundinfections


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Woundinfections

Percentage of woundinfections after APR ?


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Wondinfection after rectal surgery

Author Journal APR APR + Rtx p-value

Marijnen et al J Clin Oncol

2002

18% 29% 0.008

Vallero et al. Int J Colorectal Dis2003

26% 45% -

Bullard et al. Dis Colon Rectum

2005

23% 47% 0.005

Preoperative radiotherapy increases perineal morbidity


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Preoperative Radiotherapy

Indications

Radiotherapy (5x5Gy) : T2/3 Rectal cancer

Chemoradiation (25x2Gy + 5-FU): Locally advanced rectal cancer (large T3/4 or N+ or APR) Recurrent rectal cancer

Anal cancer


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Perineal wond closure

What are the options ?

What is your experience ?


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Perineal wond options

Leave wound open/packing with gauzes

infection & delayed healing

Temporary VAC system, secundary closure (Oxford trial)

Primary closure with/without drainage

inadequate for large defects

infection percentage 30-50%

Closure with tissue transfer


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Tissue transfer

Advantages ?


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Tissue transfer reasons

Hemostasis

Filling dead space

Sexual rehabilitation

Stimulation of healing due to Capillary ingrowth

Absorption of fluids

Control of infection rehabilitation


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Tissue transfer options

Free:

Latissimus dorsi flap

Pedicled:

Local transposition

Omental flap

Gracilis flap

Rectus Abdominis flap


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Local transposition

Gluteus maximus transposition



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Local transposition

80 min unilateral; 120 min bilateral flap

4/ 28 pts local woundinfection (14%)



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Omentumplasty

Advantages:

Well vascularised Haemostatic Non irradiated tissue Length and volume

Easy take of split skin graft Vaginal reconstruction

Disadvantages: Previously used

Complications (stomach dilatation) Laparotomy No skin island


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Surgery (I)

Omentum Plasty

Dissection of right or left GEA


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Surgery (II)

TME resection with en bloc posterior vaginal wall and left lateralpelvic wall


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Surgery (III)

Anterior TME specimen

Posterior TME specimen


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Surgery (IV)

Mobilization through transverse mesocolon

Left or right paracolic gutter


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Surgery (V)

Posterior vaginal wall removed


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Surgery (VI)

Omentum sutured to vaginal sidewalls


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Surgery (VII)

Close perineal subcutaneous fat and skin

Leave gauze in reconstructed vagina


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Omentumplasty after APR

Author Journal Patients APR APR +Omentum

Poston et al. Ann R Coll Surg

Engl 1991

53 28% 4%

John et al. Int J Colorectal Dis

1991

74 47% 18%

Wang et al. Kaohsiung J Med

Sci 1994

41 55% 23%

Hay et al. Eur J Surg

1997

165 22% 20%

Perineal infections


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Omentumplasty after APR

Review P. Nilsson Dis Colon Rectum 2006

Safe

Simple

Might be benifitial

RCT needed


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Myo-(cutaneous) transposition

pro well vascularised

outside radiation fieldadditional subcutus and skinavailable in the absence of omentumneovagina

con loss of muscle functionscar tissueinfection/complication

M. GracilisM. Rectus Abdominus (VRAM)


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Musculus Gracilis

Advantages:

Disadvantages:


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Musculus Gracilis

Advantages:

Bilateral Possible in narrow pelvic inlet

No laparotomy necessary

Low morbidity Leg function not impaired

Disadvantages:

Small volume

Vascularisation fragile

Skin island unreliable

Vermaas et al., Eur J Surg Oncol 2005


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Musculus gracilis transposition


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Peroperative result One month postoperative


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Gracilis reconstruction after rectalsurgery

Author Journal APR APR +gracilis

p-value

Shibata et al. Ann Surg Oncol

1999

46% 12% 0.03

Burke et al. Gynaecol Oncol

1999

- 16%

Vermaas et al. Eur J Surg Oncol

2005

- 28%

Potential use for postoperative woundinfections

Perineale infecties


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Vertical Rectus Abdominus Muscle

pro:

con:


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Vertical Rectus Abdominus Muscle

pro: Large volume + skin

Neovagina

con: Functional impairment

Laparotomy

Complication (necrosis, hernia)

Stoma at site of flap

Impossible after groin / transverse abdominal wall surgery


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VRAM-plasty (I)


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VRAM-plasty (II)

Large rectal and anal cancers


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Preparation of Vertical Rectus Abdominus Muscle (VRAM)

VRAM-plasty (III)


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VRAM-plasty (IV)

Preparation of skin island


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VRAM-plasty (V)

Closure of vagina with peritoneum of rectus abdominus

Rectus abdominus muscle to fill the pelvis


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VRAM-plasty (VI)

Closure of subcutaneous fat

Closure of skin


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VRAM-plasty (VII)

Closure of perineum

Reconstruction of vagina


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VRAM reconstruction after rectal surgery

Author Journal APR APR +VRAM

p-value

Kapoor et al Am Surg

2005

40% 59% 0.1

Chessin et al. Ann Surg Oncol

2005

44% 16% 0.03

Ferenschild et al. World J Surg 2005 36% 0% -

Potential decrease of postoperative woundinfections

Perineal infecties


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APR Omentumplasty, transposition

Reconstructie vagina, perineum VRAM

Perineal wondinfection Debridement

VACGracilis

Take Home Messages


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Questions ?

Filling and Reconstruction ESSO2008

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