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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
Holm et al. Br J Surg 2007
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Local transposition
80 min unilateral; 120 min bilateral flap
4/ 28 pts local woundinfection (14%)
Holm et al. Br J Surg 2007
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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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Musculus gracilis transposition
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Musculus gracilis transposition
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 ?
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