Reconstruction of the composite defect after extended abdominoperineal resection (eAPR): a clinical experience from Italy

Abdominalperineal resection (APR) represents the gold standard for lower third of rectum and anal cancer; after this wide excision, it results a large non-collapsible dead space that tends to collect fluid, increasing the risk of infection and wound dehiscence. Moreover, APR is associated to neoadjuvant/adjuvant radiation therapy with further risk of local complications. In this background, flap reconstruction after APR o eAPR represents the best strategy for minimizing tension in skin closure, providing healthy well vascularized and restoring a good functional local anatomy.

A retrospective study was performed at the Department of Plastic Reconstructive and Aesthetic Surgery at the University Hospital Città della Salute e della Scienza of Turin from March 2013 to November 2016: 11 patients were included in the study: 5 men and 6 women aged 53 to 76 years (mean ± SD age: 66 ± 7 years). All of them received eAPR (extended-APR). Seven patients required a total dose of 20Gy as neoadjuvant radiotherapy treatment and 6 patients needed adjunctive chemotherapy treatment. Skin defects size ranged from 56 to 180 cm2 (mean 114 ± 38 cm2). Skin defect less than 5 cm of maximum width was not included in the study because no major reconstructions were needed. Surgical reconstruction was planned depending on sacrectomy eventually associated to eAPR and defect size too. Planned follow-up was carried out at 1, 3, and 6 months recording clinical data, local and systemic complications, and pain evaluation at sitting position and during normal walking activity.

Wound healing was achieved in all patients within a period of 21 days. Only one patient showed partial flap necrosis and required wound surgical revision with simple skin closure. Another one patient suffered from mild venous congestion and partial flap necrosis was observed: a period of 2 weeks of negative pressure wound therapy and dressing led to complete healing of the defect (both these patients received 20Gy neoadjuvant radiotherapy). Esthetic pleasant results, high patient satisfaction, and no significant motor impairment were recorded among all patients, excepting for just one patient who reports mild walking impairment and pain at sitting position, after the 6th month follow-up. None of the patient referred significant life quality impairment and all of them expressed general high satisfaction concerning reconstructive expectations.

Many flaps can be harvested to fill and close the large defect after eAPR, with respectively advantages and disadvantages, but we found the use composite gluteal flap technique suitable for most of the patients undergoing eAPR, with good functional results and low rates of morbidity and complications.

Level of Evidence: Level IV, therapeutic study.